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SURGERY 


OP  THE 


RECTUM    AND    PELVIS 


SURGERY 


OF   THE 


RECTUM  AND  PELVIS 


BY 


CHARLES  B.  |:ELSEY,  A.M,  M.D. 

NEW   YORK 

PROFESSOR   OF   SURGERY    A.T   THE   NEW   YORK   POST-GRADUATE   MEDICAL    SCHOOL   AND   HOSPITAL  : 
MEMBER   OF   THE   NEW   YORK    ACADEMY    OP   MEDICINE,    ETC. 


WITH  TWO   HUNDRED   A  WD   EIGHTY-OWE  ILLUSTRATIONS 
AND  HALF-TONE  PLATES 


NEW    YORK 
RICHARD    KETTLES    &    CO. 

No.  129  Fifth  Avenue 
1897 


Copyrighted 

BT 

CHARLES  B.   KELSEY 

1S97 


TROW  DIRECTORY 

PRINTING  AND  BOOKBINDING  COMPANY 

NEW   YORK 


PREFACE. 


A  COMPARISON"  of  this  work  with  those  on  diseases  of  the  rectum 
by  the  same  author  which  have  preceded  it  will  show  at  a  glance  its 
increased  scope. 

The  impossibility  of  separating  diseases  of  the  rectum  in  practice 
from  so-called  gynaecology  and  genito-urinary  diseases  is  apparent 
in  such  cases  as  laceration  of  the  sphincters,  proctocele,  recto-vaginal 
fistula,  pelvic  abscess  in  women,  displacements  of  the  uterus,  acute 
and  chronic  prostatitis,  and  hypertrophy  of  the  prostate  ;  all  of 
which  are  constantly  associated  with  rectal  sj^mptoms. 

In  enlarging  this  work,  to  include  the  surgical  procedures  neces- 
sary for  the  cure  of  these  allied  affections,  the  author  has  simply  fol- 
lowed what  experience  has  proved  to  be  the  natural  course  of  his 
own  practice. 

He  can  only  hope  that  in  its  new  form  the  book  will  meet  with 
the  same  favor  that  has  attended  former  editions. 

Charles  B.  Kelsey. 

No.  18  East  Twexty-xixth  Street, 

IS'ew  York,  1897. 


CONTENTS. 


CHAPTER  I. 
Anatojiy, 1 


CHAPTEE  II. 

Geneeal  Kules  Eegaeding  Examination  and  Diagnosis,  .        .        .20 

CHAPTEE  III. 
Geneeal  Exiles  Eegaeding  Opeeations, 36 

CHAPTEE  IV. 
Congenital  Malfoemations, 50 

CHAPTEE  V. 
Peoctitis  and  Peeipeoctitis, 65 

CHAPTEE  VI. 
Abscess, 73 

CHAPTEE  VII. 
Pelytc  Abscess  in  Women, .       .80 

CHAPTEE  VIII. 

Fistula, ^       .      98 


Vlll  CONTENTS. 


CHAPTEE  IX. 
Hemoekhoids, 128 


CHAPTEE  X. 
Prolapse, 155 

CHAPTEE  XI. 
Intussusception,       . 175 

CHAPTEE  Xn. 

Non-malignant  Growths  of  the  Eectum  and  Anus,  ....    193 

CHAPTEE  XIII. 
Non-malignant  Ulceration, 210 

CHAPTEE  XIV. 

Venereal  Diseases  of  the  Eectum  and  Anus, 233 

CHAPTEE  XV. 
Non-malignant  Stricture  of  the  Eectum, 250 

CHAPTEE  XVI. 
Cancer, 276 

CHAPTEE  XVII. 

Keaske's  Excision  of  the  Eectum,       .        .        .        .        .        .        .    293 

CHAPTEE  XVIII. 
The  Formation  and  Closure  of  Artificial  Anus,     ....    310 

CHAPTEE  XIX. 

Intestinal  Eesection  and  Anastomosis, 333 


CONTENTS.  ix 

CHAPTEE  XX. 

PAGE 

Constipation— Fecal  Impaction -Peuritus — Wounds    and   Foreign 

Bodies— Neuralgia— Spasm  of  the  Sphincter,         .        .        .     350 

CHAPTEE  XXI. 

Salpingectomy  and  Oophorectomy  by  Abdominal  Incision,      .        .    391 

CHAPTER  XXII. 

Operations  on  the  Vagina, 411 

CHAPTEE  XXIII. 

Fixation  of  the  Uterus  and  Shortening  the  Eound  Ligaments,    .    447 

CHAPTEE  XXIV. 

The  Eadical  Cure  of  Hernia,     .        .        ....        .       .    461 

CHAPTEE  XXV. 

Operations  on  the  Male  Genito-urinary  Organs,     ....    481 

CHAPTEE  XXVI. 

The  Surgery  of  the  Ureters, 527 

CHAPTEE  XXVII. 

Appendicitis,     . 545 


INDEX, 555 


ILLUSTRATIONS. 


FIG.  PAGE 

1. — Dissection  of  Rectum 2 

2. — Curves  of  Rectum 3 

3. — Section  of  Rectum  and  Vagina . , 5 

4. — Section  of  Rectal  Wall 7 

5. — Columufe  Recti 7 

6. — Sacculi  of  Rectum 8 

7. — Rectal  Mucous  Membrane 9 

8. — Levator  Ani  Muscle 10 

9. — ^Levator  Ani  Muscle 11 

10. — Blood  Vessels  of  Rectum 14 

11. — Blood  Vessels  of  Rectum 15 

12. — Nerves  of  Anus 18 

13. — Bi-manual  Examination  per  Rectum 23 

14. — Edebohls's  Supports   25 

15. — Edebolils's  Supports 26 

16. — Bougie 27 

17. — Andrews's  Rectal  Sound 27 

18.— Scale  of  Rectal  Bougies i 29 

19. — Sims's  Rectal  Speculum 31 

20. — Author's  Speculum 31 

21.— Aloe  Speculum    32 

22.— Kelly's  Speculum 33 

23. — Kelly's  Speculum 33 

24. — Position  for  Examination  (Kelly) 35 

25. — Examination  with  Electric  Light  (Kelly) 35 

26. — Sterilized  Ligatures 40 

27. — Sterilized  Ligatures 40 


Xll  ILLUSTKATIONS. 


FIG. 


PAGE 


28. — Sterilizer 41 

29. — Steam  Dressing-  Sterilizer 42 

30. — Portable  Sterilizer 42 

31. —  Sponge -holder 43 

32. — Spong-e-liolder  , 43 

33. — Nozzle  for  Irrig-ator 44 

34. — Clover's  Crutcli 44 

35. — Ovariotomy  Pad 44 

36. — Kelly   Leg-liolder 45 

37. — Patient  Prepared  for   Operation , 47 

38. — Paquelin  Cautery , 43 

39. — Eectiim  Ending-  in  Blind   Pouch 52 

40. — Eectum  Ending  in  Blind  Pouch  :  Anus  Normal 53 

41. — Rectum  Ending  in  Gians  Penis 54 

42. — Eectum  Ending-  in  Bladder 5,5 

43. — Eizzoli's  Operation 62 

44. — Eetractor 62 

45. — Stricture  Due  to  Pelvic  Abscess  in  Female 81 

46. — Double  Tenaculum 84 

47. — Uterine  Dilator , 84 

48. — Curette 84 

49. — Intra-uterine  Catheter    84 

50. — Speculum 84 

51. — Uterine  Ap^Dlicator , 84 

52. — Heavy  Hysterectomy  Clamp , .  87 

53. — -Vaginal  Eetractors 87 

54. — Cleveland  Ligature-carrier 88 

55. — Heavy  Tenaculum 88 

56. — Set  of  Hagedorn  Needles 88 

57. — Needle-holder 88 

58. — Vaginal  Hysterectomy 90 

59. — Vaginal  Hysterectomy 91 

60. — Vaginal  Hysterectomy 92 

61. — Vaginal  Hysterectomy 93 

62. — Supra-vaginal  Hysterectomy    94 

63. — Supra-vaginal  Hysterectomy    94 

64. — Abdominal  Hysterectomy 96 

65. — ^Abdominal  Hysterectomy 96 


ILLUSTRATIONS.  XIU 

FIG.  PAGE 

66. — Varieties  of  Fistula 98 

67.— Fistula  with  Double  Track 99 

68.— Fistula  with  Double  Track. 99 

69.— Tubercular  Fistula 101 

70.— Director 108 

71. — Author's  Director  for  Fistula 108 

72.— Horse-shoe  Fistula 109 

73.— Horse-shoe  Fistula 110 

74. — Horse-shoe  Fistula 110 

75. — Incision  for  Horse-shoe  Fistula Ill 

76. — Incision  for  Horse-shoe  Fistula Ill 

77. — Horse-shoe  Fistula 112 

78. — Incision  for  Horse-shoe  Fistula 112 

79. — Abscess  of  Gland  of  Bartholini 113 

80.— Eecto-labial  Fistulse   114 

81.— Eecto-labial  Fistula?    115 

82. — Incisions  for  Eecto-labial  Fistulse   116 

83.— Flexible  Knife  for  Fistula 116 

84. — Cicatrix  after  Fistula 117 

85. — Cicatrix  after  Fistula 118 

86. — Operation  for  Incontinence 120 

87. — Operation  for  Incontinence 120 

88. — Incontinence  after  Fistula 121 

89. — -Operation  for  Incontinence 122 

90.— Eecto-urethral  Fistula 123 

91. — Intestino- vesical  Fistula 125 

92. — External  Venous  Hemorrhoid .  129 

93.— Bistoury 130 

94. — External  Hemorrhoid  Injected , 132 

95. — External  Cutaneous   Hemorrhoid 133 

96.— External  Hemorrhoid 134 

97. — Internal   Hemorrhoids 137 

98. — Operation  by  Ligature 142 

99. — Internal   Hemorrhoids 144 

100.— Pile  Forceps 148 

101. — Hemorrhoidal   Clamp 148 

102.— Smith's  Clamp 148 

103. — Operation  by  Excision 152 


XIV  ILLUSTRATIONS. 

FIG.  PAGE 

104.— Prolapsus 156 

105.— Prolapsus 157 

106.— Prolapsus 158 

107.— Eectal  Hernia 162 

108.— Cauterj-  Iron 169 

109. — ProlaiDse   Containing-  Peritoneum 172 

110. — Intussusception — 175 

111. — Prolapse  of  Intussusception 176 

112. — Diagram  of  Intussusception 178 

113. — Intussusception  (Park) 180 

114. — Intussusception  (Park) 181 

115. — Maunsell's  Operation  in  Intussusception  (Wig-gins) 190 

116.— Eectal  Polypus 194 

117.— Villon's  Polypus 195 

118.— Glandular  Polypus 196 

119. — Section  of  Glandular  Polypus 197 

120. — Adeno-Papilloma  of  Rectum 198 

121.— Adeno-Papilloma 199 

122.— Fibrous  Polypi 199 

123.— Fibrous  Polypi 200 

124. — Non-sj)ecific  Vegetations 203 

125.— Syphilitic  Condylomata 207 

126.— Syphilitic  Condylomata  (Taylor) 208 

127. — Congenital  Tumor  of  Anus 209 

128.— Fissure 212 

129. — Section  of  Xerve  in   Fissure 213 

130. — Tubercular  Ulceration  of  Anus 214 

131. — Fissure  -with  Hemorrhoid 215 

132.— Tubercular  Ulceration ■ 217 

133. — Tubercular  Ulceration 218 

134.— Esthiomene  (Taylor) 221 

135.— Lupus 223 

136.— Rectal  Irrigator 231 

137.— Rectal  Insufflator 231 

138.— Ointment  Applicator 232 

139. — Chancroids  of  Anus  and  Vulva 238 

140.— Syphilitic  Ulceration  of  Colon 245 

141.— Tubercular  Stricture 254 


ILLUSTRATIOISrS.  XV 

FIG.  PAGE 

142. — Anastomosis  around  Stricture  (Bacon) 269 

143. — Anastomosis  around  Stricture  (Bacon) 270 

144. — Anastomosis  around  Stricture-  (Bacon) 271 

145. — Instrument  for  Placing  Murpliy  Button 272 

146. — Operation  for  Anal  Stricture 273 

147. — Operation  for  Anal  Stricture 273 

148. — Operation  for  Anal  Stricture 274 

149. — Operation  for  Anal  Stricture 274 

150. — Operation  for  Anal  Stricture 275 

151. — Operation  for  Anal  Stricture 275 

152. — Cancer  of   Rectum  (Stimson) 277 

153. — Cancer  of  Rectum 279 

154. — Cancerous  Stricture 283 

155. — Extirpation  of  Rectum 290 

156. — Extirpation  of  Rectum 290 

157. — Extirpation  of  Rectum 291 

158.— Intestinal  Clamp 293 

159. — Incisions  in  Extirpation  of  Rectum 295 

160. — Rydygier's  Osteoplastic   Resection 296 

161.— Dissection  of  Male  Pelvis 297 

162.— Dissection  of  Female  Pelvis 298 

163. — Rectum  after  Excision 302 

164. — Sacral  Artificial  Anus 303 

165. — Truss  for  Sacral  Anus 304 

166. — Truss  for  Sacral  Anus 305 

167. — Incision  in  Lumbar  Colostomy 314 

168. — Lumbar  Colostomy 315 

169.— Colon  without  Mesentery 316 

170.— Colon  with  Short  Mesentery 816 

171. — Colon  with  Long  Mesentery 317 

172. — Inguinal  Colostomy 319 

173.— Inguinal  Colostomy 319 

174. — Inguinal  Colostomy 320 

175. — Inguinal  Colostomy 321 

176.— Inguinal  Colostomy 322 

177.— Inguinal  Colostomy 323 

178.— Spur  in  Colostomy 324 

179.— Spur  in  Colostomy 330 


XVl  ILLDSTRATIOTSrS. 

FIG.  PAGE 

180. — Enterotome  of  Dupuytren i^ 330 

181. — Szymanowski's  Operation 331 

182  — Szymanowski's  Operation 331 

183. — Szymanowski's  Operation 332 

184. — Szymanowski's  Operation 332 

185. — Abbe's  Anastomosis 335 

186. — Abbe's  Anastomosis 336 

187. — Abbe'B  Anastomosis 337 

188. — Mauusell's  Anastomosis 339 

189. — Maunseli's  Anastomosis 339 

190. — Maunseli's  Anastomosis 339 

191.— Lembert  Suture  (Park) 340 

192.— Lembert  Suture  (Park) 341 

193. — Czerny-Lembert  Suture 341 

194.— Encl-to-encl  Suture 342 

195.— Murphy's  Button 342 

196.— Murphy's  Button  in  Position 343 

197.— Murphy's  Button  Closed   343 

198.— Murphy's  Button  Closed 344 

199. — Draw-string-  for  Murphy's  Button 344 

200. — Anastomosis  by  Adossment  (Dennis) 340 

201. — Anastomosis  by  Adossment  (Dennis) 346 

202.— Lateral  Implantation  (Dennis) 347 

203.— Lateral  Implantation  (Dennis) .  347 

204. — Lateral  Implantation  (Dennis) C48 

205. — Lateral  Implantation  (Dennis) 348 

206.— Skin  in  Pruritus  Aui 365 

207. — Foreign  Body  Kemoved  from  Kectum .  883 

208. — Poreign  Body  Eemoved  from  Eectum 385 

209.— Dermoid  Cyst 403 

210.— Complete  Laceration  (after  Pozzi) ,  . .  412 

211. — Proctocele  and  Cystocele  (Munde) 413 

212. — Double  Tenaculum 414 

213.— Stellate  Laceration  of  the  Cervix  (Munde) 414 

214. — Bilateral  Laceration  of  the  Cervix  (Munde) 415 

215. — Proper  Denudation  for  Lacerated  Cervix 416 

216. — Incomplete  Denudation  for  Lacerated  Cervix 416 

217. — Sutures  in  Lacerated  Cervix 417 


ILLUSTRATIONS.  XVll 

FIG.  PAGE 

218.     Sutures  in  Lacerated  Cervix   (Kelly) 418 

219. — Cervix  after  repair  of  Laceration 418 

220. — Forceps  for  Eemoving-  Stitches  from  Cervix 419 

221. — Scissors  for  Eemoving-  Stitclies  from  Cervix 419 

222. — Hypertropliy  of  Supra- vaginal   Portion  of  Cervix 420 

223. — Uterine  and  Ovarian  Arteries  (Hyrtl) 421 

224. — Flaps  in  Amputation  of  Cervix 423 

225.— Stump  after  Amputation  of  Cervix  423 

226. — Sutures  in  Amputation  of  Cervix 424 

227. — Cervix  after  Amputation 425 

228. — Incisions  for  Laceration  of  Perineum 426 

229. — Denudation  for  Lacerated  Perineum 427 

230. — Hyar's  Colpo-Perineorrhapliy 428 

231. — Angular  Scissors  for  Denudation 428 

232. — Denudation  in  Ferine orrliaphy 429 

233.— Cleveland's  Suture 431 

234. — Denudation  in  Laceration  through  Sphincters  (Skene) 432 

235. — Sutures  in  Laceration  through  Sphincters  (Munde) 433 

236. — Rectal  Sutures  in  Complete  Laceration  (Skene) 433 

237. — Vaginal  Sutures  in  Complete  Laceration  (Skene) 434 

238. — Emmet's  Operation  for  Cystocele 435 

239.— Stoltz's  Operation  for  Cystocele 436 

240. — Combined  Stoltz  and  Hegar's  Operation  (Munde) 436 

241. — Complete  Prolapse  of  "Uterus 437 

242. — Le  Fort's  Operation  for  Closure  of  Vagina 438 

243. — Le  Fort's  Operation  for  Closure  of  Vagina 439 

244. — Emmet's  Button-hole  Operation  (Dennis) 443 

245. — Betroverted  Uterus  Pressing  upon  Rectum  (Skene) 448 

246.— Ventral  Fixation  of  Uterus 449 

247.— Ventral  Fixation  of  Uterus  (Edebohls) 452 

248. — Isolating  Round  Ligament  (Edebohls) 453 

249. — Drawing  Round  Ligament  out  of  Abdomen  (Edebohls) 454 

250. — Sutures  after  Ventral  Fixation  (Edebohls) 458 

251. — Suturing  after  Ventral  Fixation  (Edebohls) 457 

252. — Superficial  Sutures  in  Ventral  Fixation  (Edebohls) 458 

253. — Wylie's  Operation  for  Shortening  Round  Ligaments 459 

254. — Bassini's  Operation  for   Inguinal  Hernia 467 

255.  — Bassini's  Operation  for  Inguinal  Hernia 468 


Xviii  ILLUSTRATIONS. 


FIG. 


PAGE 


256.— Bassini's  Operation  for  Ing-uinal  Hernia 469 

257.— Halstead's  Operation  for  Inguinal  Hernia 470 

258.— Halstead's  Operation  for  Inguinal  Hernia 471 

259.— Halstead's  Operation  for  Inguinal  Hernia 471 

260.— Bassini's  Operation  for  Femoral   Hernia 474 

261.— Operation  for  Femoral   Hernia 474 

262.— Operation  for  Femoral  Hernia 475 

263.— Large  Ventral  Hernia • 476 

264. — Large  Yentral  Hernia 478 

265.— Hypertrophy  of  the  Prostate 495 

266.— Van  Dittel's  Incision    for  Piemoval   of    the  Seminal  Vesicles 

(Fueller) 499 

267.— Zuckerkandl's  Incision  for  Removal  of  Seminal  Vesicles 500 

268.— Bigelow's  Lithotrite -   505 

269. — Bigelow's  Evacuator 506 

270.— Section  of  Pelvis  Showing  Space  of   Eetzius 509 

271.— Syringe  for  Injecting  Bladder 510 

272.— Apparatus  for  Injecting  the  Bladder 512 

273.— Incision  for   Nephrorrhaphy 517 

274.— Relation  of  Ureters  to  Cervix  Uteri  and  Vagina  (Pozzi). . . . .   528 

275.— Kelly's  Ureteral  Catheters 530 

276. — Kelly's  Ureteral  Sounds 531 

277._Sounding  the  Pelvis  of  the  Kidney  (Kelly) 538 

278.— Catheterism  of  Ureters  (Kelly) 534 

279.— Stone  Caught  in  Eye  of  Catheter  (Kelly) 536 

280.— Stone  Removed  from  Kidney  by   Catheterization  (Kelly) ....    536 
281.— Casper's  Ureter  Cystoscope 537 


SURGERY 


OP  THE 


RECTUM    AND    PELVIS. 


CHAPTER   I. 

ANATOMY. 


The  rectum  is  the  terminal  portion  of  tlie  large  intestine,  extending 
from  the  sigmoid  ftexure  to  tlie  anus.  In  its  natural  position  its 
length  varies  in  different  persons  from  six  to  eight  inches.  Its  upper 
limit  is  difhcult  to  determine  with  accuracy,  except  from  the  fact  that 
it  is  separated  from  the  sigmoid  flexure  by  a  slight  constriction  whicli 
becomes  more  apparent  when  attempts  are  made  at  dilatation.  From 
this  upper  point  it  gradually  expands  below  into  a  pouch,  the  am- 
pulla, and  then  again  suddenly  contracts  under  the  grasp  of  the  mus- 
cles which  close  its  lower  end. 

The  curves  of  the  rectum  are  exceedingly  important  in  a  practical 
point  of  view.  There  are  two,  one  antero-posterior,  the  other  lateral. 
The  former  is  double  From  above  downward  it  follows  the  curve  of 
the  sacrum  and  coccyx,  being  concave  in  front  and  convex  behind. 
When  it  reaches  a  point  opposite  the  tip  of  the  coccyx,  it  suddenly 
reverses  its  direction,  turns  sharply  backward,  and  ends  at  the  anus, 
about  one  inch  in  front  of  the  tip  of  that  bone. 

By  this  backward  curve  of  its  lower  end,  w^iich  is  represented  in  an 
exaggerated  form  in  Fig.  2,  it  is  separated  from  the  vagina  in  the  fe- 
male, and  from  the  urethra  in  the  male,  by  a  triangular  space  having 
its  base  at  tlie  perineum,  its  upper  wall  at  the  vagina  or  urethra,  and 
its  lower  at  the  upper  wall  of  the  rectum.  The  angle  of  junction  of 
these  two  curves  is  well  marked,  measuring  from  twenty  to  thirty 


2  SURGERY    OF   THE   EECTUM    AND    PELVIS. 

degrees  ;  and  the  curve  is  not  without  influence  in  the  function  of 
defecation,  since,  by  it,  an  obstruction  is  formed  to  the  downward 
course  of  the  faeces. 

The  lateral  curve  is  generally  a  single  one  from  left  to  right,  start- 
ing at  the  left  sacro-iliac  synchondrosis  and  ending  at  the  median  line 


Fig.  1. — Dissection  of  Rectum. 


at  a  point  opposite  the  third  sacral  vertebra,  from  which  point  it 
generally  passes  straight  on  to  the  anus. 

For  convenience  of  description  the  rectum  is  usually  divided  into 
three  portions,  named  first,  second,  and  third,  from  above  downward. 
The  third  extends  from  the  anus  to  the  tip  of  the  prostate,  is  about 
an  inch  and  a  half  long,  is  firmly  closed  by  the  sphincters,  and  gives 
attachment  to  a  portion  of  the  levator  ani  muscle.      The  second  por- 


ANATOMY.  3 

tion  is  often  described  as  reaching  from  the  apex  of  the  prostate  to 
the  rectovesical  fold  of  peritoneum;  bat,  as  the  point  of  duplicature 
of  the  peritoneum  is  not  only  variable  in  different  individuals,  but  at 
different  times  in  the  same  individual,  it  is  better  to  adopt  a  fixed 
bony  point,  as  the  third  piece  of  the  sacrum  ;  in  which  case  the  mid- 
dle portion  will  measure  about  three  inches  in  length.  The  first  por- 
tion extends  from  the  third  sacral  vertebra  to  the  left  sacro-iliac  syn- 
chondrosis ;   its  lower  part  is  partially,  and  its  upper  completely, 


Fig.  2. — Exaggerated  Curve  of  the  Rectum. 


surrounded  by  peritoneum,  which,  in  the  upper  part,  forms  the  meso- 
rectum  attaching  it  to  the  sacrum. 

The  most  important  surgical  relations  of  the  rectum  are  on  the 
anterior  surface.  The  third  portion  is  surrounded  laterally  and  pos- 
teriorly by  a  bed  of  connective  tissue  rich  in  fat  and  blood-vessels. 
In  front,  however,  it  is  directly  in  relation  with  the  membranous  ure- 
thra in  the  male,  and  with  the  vagina  in  the  female  ;  though  at  the 
anus  it  is  separated  from  them  both  by  its  backward  and  downward 
course. 

In  the  second  portion,  also,  the  lateral  and  posterior  surfaces  have 
no  special  surgical  relations  ;  while  the  anterior  is  in  direct  contact 
with  the  prostate,  the  base  of  the  bladder,  tlie  seminal  vesicles,  and, 
sometimes,  at  its  upper  limit,  with  the  peritoneal  fold  of  Douglas. 


4  SURGERY    OF   THE   RECTUM    AND    PELVIS. 

This  portion  is  closely  connected  with  the  bladder  in  the  male,  and 
with  the  vagina  in  the  female,  by  connective  and  muscular  tissue ; 
and  the  two  cavities  may  easily  be  made  to  communicate  by  any 
morbid  process  or  by  a  surgical  procedure.  The  prostate,  when 
large,  may  project  over  the  sides  of  the  rectum,  or  the  latter  may  re- 
ceive the  prostate  in  a  groove  on  its  upper  surface. 

The  first,  or  iipper  portion,  unlike  the  other  two,  has  important 
surgical  relations  on  every  side.  Posteriorly  it  is  in  whole  or  part 
covered  with  peritoneum,  and  is  separated  from  the  sacrum  by  the 
pyriformis  muscle,  the  sacral  plexus  of  nerves,  and  the  branches  of 
the  internal  iliac  artery.  On  its  sides  it  is  in  contact  with  the  adjacent 
convolutions  of  small  intestine,  and  lower  down  with  the  levator  ani 
muscle  and  the  connective  tissue  of  the  iscliio-rectal  fossa.  In  the 
male  it  is  in  relation,  in  front,  with  the  posterior  surface  of  the  blad- 
der, from  which  it  is  separated  by  coils  of  small  intestine.  In  cases  of 
retention,  either  of  urine  or  fseces,  the  two  may  be  brought  into  act- 
ual contact.  In  the  female  it  is  in  relation,  anteriorly,  with  the 
broad  ligament,  the  left  ovary  and  Fallopian  tube,  the  uterus  and 
vagina.  When  the  rectum  and  uterus  are  empty,  the  coils  of  small 
intestine  pass  down  between  them  to  the  bottom  of  the  fold  of 
Douglas. 

From  these  relations  it  is  apparent  that  enlargements  and  malpo- 
sitions of  the  uterus  must  act  directly  upon  the  rectum.  The  vessels 
may  be  so  obstructed  by  uterine  disease  as  to  cause  hemorrhoidal 
troubles,  or  interfere  with  operations  for  their  relief.  The  rectum 
may  be  entirely  occluded  by  the  pressure  of  a  uterine  tumor  or  by  a 
bony  growth  or  cancerous  mass  springing  from  the  sacrum  ;  and  a 
hasty  examination  of  the  rectum  m«ay  lead  to  the  diagnosis  of  a 
tumor  in  its  anterior  wall,  when  in  reality  the  normal  uterus  alone 
is  felt.  The  advantage  of  a  rectal  examination  in  all  doubtful  cases 
of  pelvic  disease  is  also  manifest. 

The  rectum  terminates  below  in  the  anus,  which  is  tightly  closed 
by  the  external  sphincter  muscle.  The  skin  around  its  border  is  thin 
and  pigmented,  covered  with  fine  hair,  and  contains  a  great  number 
of  sebaceous  follicles  and  muciparous  glands.  The  skin  passes  deeply 
into  the  anal  orifice,  and  its  point  of  junction  with  the  mucous  mem- 
brane is  in  some  persons  indicated  by  an  indistinct  white  line.  This 
white  line  of  junction  corresponds  to  the  division  between  the  exter- 
nal and  internal  spliincter  muscles,  and  also  to  the  point  at  which 
many  of  the  terminal  filaments  of  the  internal  pudic  nerve  perforate 


ANATOMY.  .  5 

the  gut.  Botli  skin  and  mucous  membrane  at  the  anus  are  remarka- 
ble for  the  development  of  erectile  tissue ;  the  arteries  coming  from 
the  inferior  hemorrhoidal,  and  the  veins  being  very  numerous,  wind- 
ing, and  twisted. 

The  rectal  wall  is  composed,  as  are  the  other  parts  of  the  intes- 
tine, of  four  layers:  an  external  or  peritoneal;  a  muscular,  divided 
into  longitudinal  and  circular  ;  a  submucous  connective-tissue  layer  ; 
and,  most  internally,  the  mucous  membrane.  The  total  thickness  of 
these  coats  collectively  varies  greatlj^  in  different  subjects,  the  varia- 


FiG.  3. — Horizontal  Section  through  Urethra,  Vagina,  and  Anus.     (The   anus  considered  as  about 
an  inch  long,  and  including  the  terminal  portion  of  the  rectum.) 


tion  being  chiefly  in  the  muscular  coat,  the  others  remaining  pretty 
constantly  of  the  same  thickness. 

The  upper  portion  of  the  rectum  is  entirely  surrounded  by  peri- 
toneum, and  has,  besides,  a  fold  of  attachment  to  the  anterior  face  of 
the  sacrum,  known  as  the  meso-rectum.  The  meso-rectum  is  about 
four  inches  long,  blends  with  the  meso-colon  above,  and  extends  down 
as  low  as  the  third  or  fourth  sacral  vertebra,  from  which  point  its 
two  layers  are  reflected  over  the  sides  and  anterior  surface  of  the 
rectum  on  to  the  posterior  wall  of  the  nterus  and  upper  limit  of  the 
vagina  in  the  female,  and  upon  the  bladder  in  the  male,  forming  the 
cul-de-sac  of  Douglas.     The  meso-rectum  may  be  so  short  as  to  dis- 


6  SURGEKY    OF   THE    RECTUM    AND    PELVIS. 

appear  when  the  rectum  is  distended  ;  or  it  may  be  entirely  absent, 
in  which  case  the  peritoneum  passes  directly  from  the  sides  of  the 
rectum  to  the  sacrum.  Between  its  two  layers  may  be  found  some 
loose  connective  tissue,  the  hemorrhoidal  vessels  and  nerves,  and  the 
lymphatics.  In  women  it  generally  covers  the  upper  part  of  the 
posterior  vaginal  wall,  so  that  the  latter  is  separated  from  the  rectum 
by  peritoneum  for  about  one-third  of  an  inch.  By  every  expansion 
of  the  bladder  or  rectum,  as  well  as  by  tumors  of  the  pelvis,  the  fold 
is  carried  farther  away  from  the  anus,  as  may  easily  be  demonstrated 
on  the  cadaver  by  forcible  injections  of  the  bladder. 

In  the  fact  that  the  muscular  coat  is  arranged  in  two  layers,  an 
external  longitudinal  and  an  internal  circular,  the  rectum  resembles 
the  other  portions  of  the  alimentar}^  canal ;  but  in  the  farther 
arrangement  of  its  fibres  it  resembles  the  oesophagus  more  closely 
than  the  intermediate  portions.  The  fibres  are  spread  out  into  two 
uniform  layers,  and  are  not  arranged  in  bands  crossing  each  other  in 
basket  network  and  leaving  sacculi  between  the  meshes  as  in  the 
large  intestine. 

The  longitudinal  fibres  are  the  direct  continuation  of  the  three 
longitudinal  bands  of  the  large  intestine.  Upon  reaching  the  rectum 
these  blend  into  one  continuous  sheath,  which,  however,  is  somewhat 
heavier  on  the  anterior  surface  of  the  bowel  than  on  any  other. 

The  circular  layer  is  reinforced  at  certain  points,  notably  at  the 
internal  sphincter,  which  is  merely  a  collection  of  these  fibres,  and 
at  various  points  higher  up  where  they  are  again  gathered  into  bun- 
dles either  partly  or  completely  surrounding  the  bowel,  known  as 
the  third  sphincter.  This  supposed  muscle  will  be  described  more 
fully  later. 

The  submucous  tissue  forming  the  bed  upon  which  the  mucous 
membrane  rests  is  sufficiently  lax  to  permit  of  considerable  sliding 
of  the  mucous  membrane  on  the  muscular  coat.  In  it  the  blood-ves- 
sels ramify,  and  from  it  perpendicular  processes  are  given  off  which 
perforate  both  the  internal  and  external  muscular  layers  and  are 
finally  lost  in  the  sheaths  of  the  muscular  fibres,  or  go  entirely 
through  the  muscular  layer  and  blend  with  the  fibrous  stroma  of  the 
surrounding  fatty  tissue.  These  processes  from  the  submucous  tis- 
sue, together  with  the  Ij'^mph  and  blood  vessels,  serve  to  bind  the 
various  layers  of  the  rectal  wall  together  (Fig.  4). 

The  mucous  membrane  of  the  rectum  corresponds  in  its  general 
characters  with  that  of  the  other  parts  of  the  bowel,  being  modified, 


ANATOMY. 


however,  in  certain  particulars  to  suit  its  location  and  function.  Its 
thickness  is  about  three  quarters  of  a  mm. ;  it  is  redder  and  more 
vascular  than  that  of  other  parts  of  the  large  intestine  ;  it  glides 
freely  on  the  tissue  beneath,  and  is  so  ample  as  to  be  gathered  into 


Fig.  4. — Section  of  Rectal  Wall. 

folds  at  various  points,  which  are  of  considerable  surgical  and  ana- 
tomical interest.  At  its  point  of  union  with  the  skin  of  the  anus, 
it  is  gathered  into  vertical  folds  which  diminish  when  the  bowel  is  dis- 
tended, but  do  not  entirely  disappear,  and  hence  are  not  due  solely 
to  the  contraction  of  the  sphincter.  These  vertical  folds  have  received 
the  name  of  columncB  rectU  or  columns  of  Morgagni. 

Between   the  lower  ends  of  the  columncB  recti  little  arches  are 
sometimes  stretched  from  one  to  the  other,  forming  pouches  of  skin 


Fig.  5. — Columnse  Recti. 

and  mucous  membrane.  These  are  more  developed  in  old  people,  and 
may  retain  small  pieces  of  hardened  faeces  or  foreign  bodies  in  their 
oavities,  which  are  directed  upward,  and  thus  give  rise  to  suppura- 
tion and  abscess. 

These  little  pouches,  or  sacculi,  have  quite  recently  been  brought 


8  SURGERY    OF   TJ£E    RECTUM    AND    PELVIS. 

into  rather  an  undue  prominence  by  the  attempts  of  certain  charla- 
tans to  locate  in  them  many  of  the  causes  of  rectal  9.isease.  They 
have  always  been  known  to  anatomists,  as  Figures  5  and  6  will  prove  ; 
but  the  fact  is  that  both  these  drawings,  and  more  especially  the  first 
one,  are  diagrammatic  exaggerations  for  the  sake  of  clearness. 

For  some  years  I  have  been  on  the  watch  for  these  poaches  in  my 
rectal  examinations,  with  the  result  of  concluding  that  they  do  not 
generally  exist  to  any  such  degree  as  these  diagrams  would  indicate ; 


Fig.  6. — Sacculi  of  Rectum  (Hnrner). 


and  that,  even  when  one  or  two  of  them  are  found,  they  are,  in  the 
majority  of  cases,  of  no  pathological  significance. 

The  muscles  which  may  properly  be  included  in  a  description  of 
the  rectum  and  anus  are  the  external  and  internal  sphincters,  the 
levator  ani,  ischio-coccygeus,  retractor  recti  or  recto-coccygeus,  and 
the  transversus  perinsei. 

The  external  sphincter  muscle  is  a  thin,  subcutaneous  layer  of 
voluntary  fibres,  about  half  an  inch  broad  on  each  side  of  the 
anus,  surrounding  it  in  the  form  of  an  ellipse,  and  having  a  narrow, 
pointed  insertion  anteriorly  and  posteriorly.     It  is  about  two  centi- 


ANATOMY.  9 

metres  thick,  and  is  divided  into  a  superficial  and  a  deep  portion. 
The  superficial  is  inserted,  both  in  front  and  behind,  into  the  subcu- 
taneous cellular  tissue.  The  deeper  and  thicker  portion  is  inserted 
posteriorly  by  a  narrow,  fiat  tendon  into  the  posterior  surface  of  tlie 
fourth  coccygeal  vertebra.  Anteriorly  it  is  inserted  into  the  central 
tendon  of  the  perineum  in  common  with  the  transversus  perinsei  and 
bulbo-cavernosus,  and  in  women  with  the  sphincter  vaginae.  The 
action  of  the  muscle  is  to  close  the  anus  and,  under  the  control  of  the 
will  to  antagonize  the  proper  dilators  of  the  anus  as  well  as  the  peri- 
staltic action  of  the  bowel  and  the  contraction  of  the  diaphragm. 
The  superficial  band  of  fibres  acts  only  in  puckering  the  skin.     The 


Fig.  7, — Section  of  the  Rectal  Mucous  Membrane.  1.  Follicles  of  Lieberkuhn.  2.  Muscular 
layer  of  mucous  membrane.  3.  Submucous  connective  tissue  and  vessels,  with  a  solitary  closed 
follicle,  over  which  the  tubular  follicles  are  wanting. 


nerve-supply  comes  from  the  hemorrhoidal  branch  of  the  internal 
pudic  and  the  hemorrhoidal  branch  of  the  fourth  sacral  nerve. 

Great  variations  will  be  found  in  this  muscle  in  different  persons. 
In  some  it  is  strong,  in  others  weak.  In  some  it  closes  the  anus  so 
tightly  that  a  finger  cannot  be  inserted  without  pain  ;  in  others  a 
full-sized  Sims'  speculum  can  be  passed  without  difficult3^ 

The  internal  sphincter  is  an  involuntary  muscle  situated  imme- 
diately above  and  partly  within  the  deeper  portion  of  the  external 
sphincter,  being  separated  from  it  b}^  a  layer  of  fatty  connective  tis- 
sue. Its  thickness  is  about  two  lines  ;  its  vertical  measurement, 
from  half  an  inch  to  an  inch  ;  and  it  is  a  direct  continuation  of  the 
involuntary  circular  fibres  of  the  bowel,  growing  thicker  and  stronger 
as  they  approach  the  anus.  It  also  is  supplied  by  the  hemorrhoidal 
branch  of  the  internnl  pudic. 

In  dissecting  this  muscle  for  demonstration,   it   should   be   ap- 


10 


SURGERY    OE   THE   RECTUM    AND    PELVIS. 


proached  from  the  mucous  surface  of  the  bowel.  It  will  be  found 
answering  to  this  description  in  a  general,  way  in  most  cases,  but  is 
subject  to  many  variations,  due  to  its  different  degrees  of  develop- 
ment in  different  subjects.  In  some  it  is  very  well  marked,  in  others 
scarcely  distinguishable  from  the  rest  of  the  circular  muscular  fibres. 
The  levator  and  ischio-coccygeus  muscles  form  a  true  diaphragm 
to  the  pelvis  by  giving  an  uninterrupted  muscular  and  tendinous 
plane  from  tlie  lower  border  of  the  pyriformis,  behind,  to  the  arch  of 


Fig.  8. — Side  View  of  Levator  Ani. 


the  pubes  in  front.  That  part  which  is  named  ischio-coccygeus  is 
usually  described  as  a  separate  muscle,  though  in  no  way  differing 
in  function  from  the  larger  portion,  and  only  distinguishable  from  it 
by  its  more  tendinous  structure.  It  is  situated  just  in  front  of  the 
sacro-sciatic  ligaments,  and  arises  by  aponeurotic  fibres  from  the 
sides  and  tip  of  the  spine  of  the  ischium,  from  the  anterior  surface  of 
the  lesser  sacro-sciatic  ligament,  and  often  from  the  posterior  part  of 
the  pelvic  fascia.  It  is  inserted,  also  by  aponeurotic  fibres,  into  the 
border  of  the  coccyx  and  lower  part  of  the  border  of  the  sacrum. 
Owing  to  its  tendinous  origin  and  insertion,  the  greater  part  of  the 


ANATOMY. 


11 


muscle  is  composed  of  aponeurotic  fibres.  It  is  in  relation  superiorly, 
by  its  concave  surface,  with  the  rectum ;  interiorly,  by  its  convex 
surface,  with  the  sacro-sciatic  ligaments  and  the  gluteus  maximus ; 
posteriorly  its  border  is  in  contact  with  the  lower  border  of  the  pyri- 
formis  ;  and  anteriorly  it  is  directly  continuous  with  the  fibres  of  the 
levator  ani.  Its  action  is  to  draw  the  coccyx  to  its  own  side,  or, 
when  both  muscles  act  together,  to  fix  that  bone  and  prevent  its 
being  thrown  backward  in  defecation.  Its  nerve-supply  is  from  the 
anterior  branch  of  the  fourth  sacral  nerve. 


Fig.  9. — Levatores  Ani  seen  from  Behind. 


The  levator  ani  proper,  which  constitutes  the  remaining  portion 
of  the  pelvic  diaphragm,  is  in  its  general  shape  an  inverted  cone, 
supporting  the  pelvic  contents  in  its  cavity  and  allowing  the  rectum 
and  prostate  to  pass  through  its  apex.  Considering  each  lateral  half 
of  the  muscle  apart,  we  find  it  made  up  of  a  delicate  layer  of  muscu- 
lar fibres  forming  a  thin,  curved,  and  quadrilateral  sheet,  broader 
behind  than  in  front.  Its  upper  border  is  stretched  across  the  pelvis 
from  the  pubes  to  the  spine  of  the  ischium,  arising  from  both  these 
bony  points  and  from  the  tendinous  line  of  union  of  the  pelvic  with 
the  obturator  fascia,  which  runs  antero-posteriorly  between  them. 
Its  attachment  to  the  pubic  bone  is  at  a  point  on  its  inner  surface 


12  SUEGERY    OF   THE   IlECTUM    AND    PELVIS. 

near  the  middle  of  tlie  descending  ramus  and  a  little  to  one  side  of 
tiie  symphysis.  This  attachment  will  be  found  to  vary  somewhat  in 
different  dissections,  being  sometimes  a  little  higher  or  a  little  lower 
on  the  bone,  and  sometimes  on  the  cartilage  between  the  bones.  The 
muscular  fibres  may  also  be  traced  at  times  upward  into  the  pelvic 
fascia  above  its  junction  with  the  obturator  (Figs.  8  and  9). 

From  this  extensive  though  delicate  and  in  great  part  membranous 
origin,  the  fibres  proceed  downward  and  inward  toward  the  median 
line.  Those  most  anterior  unite  with  those  of  the  opposite  side 
beneath  the  neck  of  the  bladder,  the  prostate,  and  the  adjacent  por- 
tion of  the  urethra.  These  fibres  are  concealed  by  the  pubo-prostatic 
ligament  or  anterior  fold  of  the  recto-vesical  fascia,  from  which  they 
also  sometimes  take  origin  in  part.  They  are  in  relation,  in  front, 
with  the  posterior  surface  of  the  triangular  ligament.  This  portion 
is  sometimes  separated  from  the  main  body  of  the  muscle  by  a  cellu- 
lar interval,  similar  to  those  often  found  in  other  parts  of  this  thin 
muscular  sheet. 

The  fibres  which  arise  from  the  tip  of  the  spine  of  the  ischium  are 
inserted  into  the  side  of  the  tip  of  the  coccyx,  while  the  fibres  imme- 
diately in  front  of  these  (precoccygeal)  unite  with  those  of  the  oppo- 
site side  in  the  median  line  and  form  a  raphe  which  extends  from 
the  point  of  the  coccyx  to  the  posterior  border  of  the  sphincter,  and 
thus  complete  the  floor  of  the  pelvis. 

The  fibres  which  arise  indirectly  from  the  upper  part  of  the  obtura- 
tor foramen  and  from  the  brim  of  the  pelvis  by  means  of  the  pelvic 
fascia,  pass  downward  and  inward,  forming  a  curve  with  its  concavity 
upward,  and  may  be  divided  into  vesical  and  anal.  The  vesical  pass 
into  the  sides  of  the  bladder.  The  anal  fibres  in  part  pass  backward 
and  meet  behind  the  bowel,  and  in  part  blend  with  those  of  the  exter- 
nal sphincter  at  its  upper  border,  there  being  no  distinct  line  of  sepa- 
ration between  the  two  muscles. 

The  relations  of  the  levator  ani  are  of  great  surgical  importance. 
Superiorly  its  surface  is  covered  by  the  superior  pelvic  fascia  (the 
rectovesical  layer  of  the  pelvic  fascia),  which  separates  it  from  the 
peritoneum  and  pelvic  organs.  The  space  between  this  fascia  and  the 
peritoneum  is  the  superior  pelvi-rectal  space  of  Richet.  Its  inferior 
surface  is  separated  from  the  obturator  internus  muscle  by  the  obtura- 
tor fascia,  and  beneath  this  is  the  ischio-rectal  fossa.  The  posterior 
part  of  the  muscle  is  in  relation  with  the  gluteus  maximus. 

The  actions  of  this  muscle  are  various.     First,  it  acts  as  a  support 


ANATOMY.  13 

to  the  pelvic  organs,  and  antagonizes  the  diaphragm  and  abdominal 
muscles  when  they  act  upon  the  abdominal  contents.  By  enclosing 
the  neck  of  the  bladder  the  muscle  acts  upon  it  also,  and  in  the  act 
of  defecation,  when  the  muscle  is  contracted  to  open  the  anus,  the 
neck  of  the  bladder  is  pressed  upon  and  the  urethra  closed.  By  en- 
closing the  bladder,  vesiculse  seminales,  prostate,  and  rectum  in  its 
grasp,  tlie  muscle  produces  a  sympathy  among  these  parts  which 
will  often  be  found  very  distressing  in  diseases  of  the  rectum  or  after 
operations  for  their  relief — such  as  impossibility  of  micturition,  erec- 
tions, and  lancinating  pain  due  to  spasmodic  action  of  the  muscle. 
The  muscle  also  aids  the  longitudinal  fibres  of  the  rectum  in  their 
opposition  to  the  dragging  of  the  faeces  ;  and  the  anal  fibres  also 
draw  the  rectum  upward  and  forward,  and  compress  it  on  the  sides, 
and  thus  aid  in  the  expulsion  of  its  contents. 

The  voluntary  sphincteric  action  of  this  muscle  in  connection 
with  the  ischio-coccygeus  is  of  considerable  power.  It  is  brought  to 
bear  at  a  point  about  an  inch  and  a  half  above  the  anus,  and  no 
doubt  in  a  measure  accounts  for  the  partial  control  over  the  passage 
of  ffeces  often  seen  after  destruction  of  both  the  internal  and  exter- 
nal sphincters. 

The  muscle  receives  a  filament  from  the  fourth  sacral  nerve  on 
its  pelvic  surface,  and  another  from  the  internal  pudic. 

The  transversus  perin?ei  also  has  an  action  in  defecation.  Its  fibres 
do  not  always  blend  with  those  of  the  opposite  side  in  the  median 
raphe,  but  the  two  muscles  are  sometimes  continuous,  traversing  the 
anterior  extremity  of  the  external  sphincter.  In  such  a  case  the  two 
muscles  form  a  continuous  half- ring,  the  concavity  of  w^hich  is  directed 
backward  and  embraces  the  anterior  part  of  the  rectum,  assisting 
powerfully  in  defecation  by  pressing  the  anterior  against  the  pos- 
terior wall  of  the  bowel  in  conjunction  with  the  external  sphincter. 

Arteries. — The  rectum  is  supplied  with  blood  from  five  arteries, 
one  single  and  two  pairing. 

The  superior  hemorrhoidal  is  single  and  is  a  direct  branch  of  the 
superior  mesenteric.  It  is  the  direct  continuation  of  the  parent  trunk, 
passing  into  the  pelvis  behind  the  rectum  in  the  fold  of  the  meso- 
rectum,  and  dividing  into  two  branches  which  extend,  one  on  each 
side  of  the  bowel,  to  its  lower  end.  About  five  inches  from  the  anus 
these  subdivide  into  smaller  branches,  about  seven  in  number,  which 
pierce  the  muscular  coat  about  two  inches  lower  down.  Then  they 
descend  between  the  mucous  and  muscular  layers  at  regular  inter- 


14 


SURGERY  OF  THE  RECTUM  AND  PELVIS. 


vals  to  the  end  of  the  bowel,  where  they  communicate  in  loops  oppo- 
site the  internal  sphincter,  and  anastomose  with  the  terminal  fila- 
ments of  the  middle  and  inferior  hemorrhoidal  arteries. 

The  middle  hemorrhoidal  arteries — one  on  each  side — are  not  con- 
stant in  their  origin,  sometimes  coming  from  the  hypogastric  or  the 
inferior  vesical,  and  sometimes  from  other  sources. 

The  inferior  hemorrhoidal  arteries — also  pairing — are  usually 
given  off  from  the  internal  pudic  near  the  point  where  it  crosses  the 


YHM. 


Mim. 


VBlE 


Fig.  10.— Blood-supply  of  Rectum. 

tuber  ischii.  They  cross  through  the  fat  of  the  ischio-rectal  fossae, 
and  are  distributed  with  the  middle  hemorrhoidal  to  the  lowest  part 
of  the  rectum,  and  to  the  anus  and  adjacent  skin. 

Veins. — There  are  three  sets  of  rectal  veins,  as  there  are  three  sets 
of  arteries — the  superior,  middle,  and  inferior  ;  and  these  are  so 
arranged  as  to  form  two  distinct  venous  systems — the  one,  rectal, 
and  returning  its  blood  to  the  vena  portse  ;  the  other,  anal,  returning 
its  blood  through  the  internal  iliac.  The  first,  or  rectal  circulation, 
is  made  up  of  the  superior  hemorrhoidal  vein  ;  the  second,  or  anal, 


AISTATOMY. 


15 


is  made  up  of  the  middle  and  inferior  hemorrlioidal  veins,  the  middle 
receiving  its  blood  from  the  anus,  and  the  inferior  from  the  adjacent 
integument.  The  middle  hemorrhoidal  ascends  obliquely  into  the 
ischio-rectal  fossa  ;  the  inferior  starts  horizontally  from  the  skin  of 
the  anus  and  empties  into  the  internal  pudic. 

The  middle  hemorrhoidal  is  formed  from  two  venous  trunks,  one 
on  the  anterior,   the  other  on  the  posterior  aspect  of  the  rectum. 


v:h,e 


V.H.E 


Fig.  11.— Rectal  Veins. 


which,  by  anastomosing  with  the  corresponding  branches  from  the 
opposite  side,  surround  the  sphincter  in  a  venous  circle.  From 
this  circle  spring  the  collateral  branches,  which,  by  their  successive 
division  and  anastomoses  form  a  true  venous  plexus.  The  inferior 
hemorrhoidal  vein  also  has  a  plexiform  arrangement  at  its  origin, 
but  its  branches  are  situated  between  the  skin  and  the  inferior  bor- 
der of  the  external  sphincter.  The  rectal  pouch  is  not,  therefore, 
supplied  with  blood  from  the  external  hemorrhoidal  veins,  but  only 
the  anus  and  the  region  of  the  sphincters. 


16  SURGERY    OF   THE    RECTUM    AND    PELVIS. 

When,  on  the  other  hand,  the  venous  circulation  of  the  rectum 
proper -is  injected  from  the  inferior  mesenteric  vein,  three  or  four  large 
venous  trunks  may  be  seen  on  the  external  surface  of  the  rectum, 
ascending  on  the  sides  and  posteriorly  (Figs.  10  and  11).  These  veins 
make  their  appearance  suddenly  by  five  or  six  branches,  which  per- 
forate the  wall  of  the  bowel  about  three  inches  from  the  margin  of 
the  anus.  If  the  rectum  be  opened  longitudinally,  and  the  mucous 
membrane  dissected  up  to  a  sufficient  height  (about  four  inches),  it 
will  be  seen  that  these  five  or  six  large  veins,  already  visible  on  the 
outside  of  the  bowel,  come  from  within,  and  that  they  have  already 
pursued  quite  a  long  course  under  the  mucous  membrane.  They  are 
formed  by  collateral  branches,  and  especially  by  about  a  dozen 
primitive  branches,  which  originate  about  half  an  inch  above  the 
anus  and  ascend  in  parallel  and  Hexous  lines  for  several  centime- 
tres to  unite  into  common  trunks.  Each  of  these  little  ascending 
branches  has  its  origin  in  a  minute  pool  of  blood,  the  size  of  which 
varies  in  the  normal  state  from  that  of  a  grain  of  wheat  to  that  of  a 
small  pea. 

These  little  sacs  are  arranged  in  a  circular  form  around  the  ex- 
tremity of  the  rectum.  If  carefully  dissected  they  may  be  seen  to 
be  connected  with  the  little  veins  before  mentioned,  and  also  with  an- 
other little  vein  which  perforates  the  internal  sphincter  near  its  lower 
edge,  and  empties  into  one  of  the  rudimentary  branches  of  the  exter- 
nal hemorrhoidal  plexus.  Many  of  these  little  communicating 
branches  between  the  external  and  internal  hemorrhoidal  systems 
pass  through  the  substance  of  the  external  sphincter.  It  results  from 
this  that  when  the  external  sphincter- is  contracted  the  anastomosis 
between  the  two  systems  is  prevented. 

The  disposition  of  the  rectal  veins  into  two  distinct  systems,  the 
one  internal  and  the  other  external,  is  fully  in  conformity  with  our 
knowledge  of  the  development  of  the  rectum  and  anus.  The  rectal 
cul-de-sac  is  at  first  situated  at  some  distance  from  the  perineum, 
and  as  it  descends  it  carries  with  it  its  own  proper  vascular  supply. 
The  anal  depression  is  of  necessity  provided  with  an  independent  set 
of  veins,  and  when  the  rectum  and  anus  are  finally  united  into  one 
canal  the  two  venous  systems  also  unite. 

The  internal  hemorrhoidal  veins  also  communicate  freely  with 
other  branches  of  the  internal  iliac  around  the  trigone  of  the  bladder 
by  means  of  minute  branches,  from  one-half  to  one  mm.  in  diameter, 
which  pass  through  the  prostate  and  vesiculse  seminales. 


ANATOMY.  17 

JSerxies. — The  nerves  of  the  rectum  and  anus  are  derived  from 
botli  the  cerebro-spinal  and  sympathetic  systems.  The  former  are 
branches  from  the  sacral  plexus,  the  latter  from  the  mesenteric  and 
hypogastric  plexuses.  The  spinal  nerves  are  derived  from  the  third 
and  fourth  sacral,  which  supply  visceral  branches  to  all  the  pelvic 
organs,  anastomosing  v^^ith  branches  from  the  sympathetic.  The 
muscular  branches  from  the  same  nerves  have  already  been  spoken 
of  in  connection  with  the  individual  muscles.  The  fifth  sacral  nerve 
also  sends  a  small  twig  to  the  coccygeus.  The  posterior  branch  of 
the  superficial  perineal  nerve  from  the  internal  pudic  supplies  the 
skin  in  front  of  the  anus,  while  the  anterior  branch  gives*  several 
small  filaments  to  the  levator  ani. 

The  inferior  hemorrhoidal  branch  from  the  pudic  supplies  the 
lower  end  of  the  rectum,  the  external  sphincter,  and  the  skin  of 
the  anus.  This  nerve  may  come  direct  from  the  sacral  plexus 
through  the  lesser  sacro-sciatic  notch.  The  posterior  branches  of 
the  sacral  nerves  also  supply  the  skin  over  the  coccyx  and  around 
tlie  anus. 

The  tonic  contraction  of  the  external  sphincter  muscles  is,  in  part 
at  least,  due  to  the  influence  of  a  nerve-centre  located  in  the  lum- 
bar region  of  the  spinal  cord.  If  the  nerve-connection  of  the  sphinc- 
ter with  the  spinal  cord  be  severed,  relaxation  of  the  muscle  takes 
place.  The  fact  that  division  of  the  cord  in  the  dorsal  region  does 
not  affect  the  sphincter,  except  temporarily  by  shock  or  depression, 
proves  that  this  centre  is  not  located  above  the  lumbar  region.  This 
nerve-centre  is  subject  to  various  influences  ;  and  the  sphincter  may 
either  be  relaxed,  or  its  tonic  contraction  increased,  by  local  stimu- 
lation, or  by  the  influence  of  the  will  or  emotions. 

Though  the  dependence  of  the  sphincter  for  its  tonic  contraction 
upon  the  lumbar  nerve-centre  seems  so  great,  still  it4s  not  absolute. 
In  the  case  of  a  man  in  whom  the  sacral  nerves  were  entireh^  para- 
lyzed by  an  injury,  and  in  whom,  therefore,  there  was  no  nerve-con- 
nection with  the  lumbar  centre  except  perhaps  through  the  sympa- 
thetic, Gower  observed  the  maintenance  of  a  certain  amount  of  tonic 
contraction,  which  could  be  inhibited  and  relaxation  produced  by 
stimulation  of  the  mucous  membrane  of  the  rectum  and  anus.  From 
this  it  would  appear  that  the  tonic  contraction  of  the  sphincter,  as  is 
known  to  be  the  case  in  the  arterial  system,  is  habitually  dependent 
on  a  spinal  centre,  but  may,  nevertheless,  exist  without  the  action  of 
that  centre.     The  paralysis  of  the  muscle  which  follows  brain  lesions 


18 


SURGERY   OF   THE   RECTUM    AND   PELVIS. 


is  probably  due  merely  to  inliibition  of  the  spinal  centre,  and  not  to 
the  injury  of  any  centre  located  in  the  cerebrum. 

The  distribution  of  the  spinal  nerves  serves  to  explain  many  of  the 
reflex  and  so-called  anomalous  symptoms  of  pain  which  are  encoun- 
tered in  diseases  of  the  rectum  and  anus. 

The  chief  nerve-supply  of  the  rectum  is  at  the  lower  portion  and 
around  the  anus — the  middle  and  upper  portions  possessing  very  lit- 
tle sensibility ;  so  little,  in  fact,  that  the  gravest  diseases,  such  as 
cancer  or  ulceration,  may  exist  and  not  manifest  themselves  by  pain. 


h  c 


Fig.  13.— Ntrves  of  Anus. 


The  pelvic  plexuses  of  the  sympathetic  are  placed  one  on  either 
eide  of  the  rectum  and  vagina.  Each  is  composed  of  prolongations 
from  the  hypogastric  plexus  above,  united  with  branches  from  the 
sacral  ganglia.  The  spinal  branches  to  the  sympathetic  are  mostly 
from  the  third  and  fourth  sacral  nerves.  From  the  back  part  of  the 
plexus  thus  formed  are  given  off  the  inferior  hemorrhoidal  nerves, 
which  join  with  the  superior  hemorrhoidal  from  the  inferior  mesen- 
teric artery  and  perforate  the  rectal  wall. 

Lymphatics. — The  lymphatic  vessels  of  the  rectum  are  arranged 
like  those  of  the  intestine,  generally  in  two  layers  :  one  beneath  the 
peritoneum  and  one  between  the  mucous  and  muscular  coats.  Imme- 
diately after  leaving  the  bowel  some  of  the  vessels  pass  through 
small  adjacent  glands,  and  all  finally  enter  the  glands  in  the  hollow 
of  the  sacrum,  or  those  higher  up  in  the  loin. 

But  just  as  there  is  an  internal  and  external  system  of  veins,  one 
proper  to  the  rectum,  the  other  to  the  anus,  so  is  there  another  lym- 
phatic system,  which  comes  from  the  integument  around  the  anus 
and  passes  to  the  glands  in  the  groin  ;  and  these  two  sets  of  vessels 
freely  communicate  with  each  other.  A  knowledge  of  this  fact  is  of 
importance  in  the  diagnosis  of  cancer  of  the  rectum  ;  and  the  glands 


ANATOMY.  19 

wliicli  are  deep  in  the  pelvis  along  the  sacrum  should  always  be  felt 
for,  as  well  as  those  located  in  the  groin. 

The  supposed  "  third  sphincter"  of  the  rectum  has  been  a  matter 
of  study  and  discussion  for  many  years.  All  that  is  reall}^  known 
about  it  may  be  briefly  summarized  as  follows  : 

What  has  been  so  often  and  so  differently  described  as  a  third  or 
superior  sphincter  ani  muscle  is  in  reality  nothing  more  than  a  band 
of  the  circular  muscular  fibres  of  the  rectum. 

This  band  is  not  constant  in  its  situation  or  size,  and  may  be 
found  anywhere  over  an  area  of  three  inches  in  the  upper  part  of  the 
rectum. 

The  folds  of  mucous  membrane  (Houston's  valves)  which  have 
been  associated  with  these  bands  of  muscular  tissue  stand  in  no 
necessary  relation  with  them,  being  also  inconstant,  and  varying 
much  in  size  and  position  in  different  persons. 

There  is  nothing  in  the  physiology  of  the  act  of  defecation,  as  at 
present  understood,  or  in  the  fact  of  a  certain  amount  of  continence 
of  faeces  after  extirpation  of  the  anus,  which  necessitates  the  idea  of 
the  existence  of  a  superior  sphincter. 

When  a  fold  of  mucous  membrane  is  found  which  contains  mus- 
cular tissue,  and  is  firm  enough  to  act  as  a  barrier  to  the  descent  of 
the  fseces,  the  arrangement  may  fairly  be  considered  an  abnormality, 
and  is  very  apt  to  produce  the  usual  signs  of  stricture. 


CHAPTER  II. 

GENERAL  RULES  REGARDING  EXAMINATION  AND  DIAGNOSIS. 

To  one  wlio  has  been  trained  in  the  habit  of  making  a  diagnosis 
before  undertaking  treatment,  it  seems  superfiuoiis  to  insist  upon  the 
necessity  of  a  pliysical  examination  in  cases  of  rectal  disease.  The 
symptomatology  alone  may  be  of  great  value  in  the  diagnosis  of 
rectal  disease,  but  it  is  almost  never  sufficient  in  itself  for  a  diag- 
nosis. There  is  a  train  of  symptoms  common  to  almost  all  diseases 
of  this  part,  and  which  infallibly  point  to  trouble  of  some  kind,  but 
they  do  not  tell  what  that  trouble  is.  For  this  reason  the  practitioner 
who  attempts  to  treat  a  case  of  supposed  disease  of  the  rectum  with- 
out first  making  a  direct  examination,  uselessl}^  risks  his  reputation 
as  a  diagnostician  ;  and  in  my  own  practice  I  am  guided  b}^  the 
simple  rule  that  patients,  male  or  female,  who  have  not  3'et  come  to 
the  point  which  makes  them  willing  to  submit  to  an  examination, 
have  not  yet  reached  a  point  which  admits  of  treatment.  An  exam- 
ination, especially  in  women,  is  sometimes,  though  not  often,  difficult 
to  obtain,  and  the  dread  of  it  keeps  many  sufferers  from  seeking 
relief  ;  but  still  the  rule  I  have  laid  down  is  the  only  safe  one,  and 
the  surgeon  who  allows  himself  to  be  persuaded  into  "recommending 
something  for  piles"  will  sooner  or  later  have  a  mistake  in  diagnosis 
laid  to  his  charge,  nor  will  the  fact  that  he  was  moved  by  considera- 
tion for  the  patient's  sensibilities  save  him  from  blame. 

I  generally  find  that,  to  one  unaccustomed  to  the  examination  of 
patients  suffering  with  disease  of  the  rectum  or  pelvis,  the  diagnosis 
is  surrounded  by  many  imaginar}^  difficulties.  The  same  idea  is  well 
fixed  in  the  minds  of  patients  who,  under  the  false  impression  that 
an  examination  and  diagnosis  necessarily  mean  a  painful  use  of  in- 
struments, will  defer  treatment  until  disease  has  made  irreparable 
progress.  The  surprise  of  such  patients  when  a  diagnosis  is  made 
by  mere  sight  of  the  anus,  or  at  most  by  a  painless  digital  examina- 
tion, is  onl}^  equalled  by  that  of  the  young  practitioner  when  he  is 


GENERAL    RULES    EEGARDING   EXAMINATION   AND    DIAGNOSIS.       21 

told  that  only  in  exceptional  cases  is  it  necessary  to  use  any  speculum 
whatever. 

The  secret  of  successful  diagnosis  of  these  diseases  consists  in 
taking  nothing  for  granted.  Ever}^  affection  of  the  lower  ten  inches 
of  the  bowel  can  be  either  seen  or  felt,  if  the  practitioner  will  only 
take  the  necessary  trouble  to  go  about  it  in  the  proper  way  ;  and  a 
disease  which  can  be  felt  or  looked  at  is  generally  easy  of  diagnosis. 
The  man  who  fails  to  detect  the  nature  of  a  rectal  trouble  is  generall}^ 
the  one  who  has  either  refused  to  employ  the  necessary  and  yet  sim- 
ple methods  by  which  alone  a  diagnosis  can  be  reached,  or  else  has 
not  sufficient  skill  and  experience  to  interpret  the  physical  conditions 
found. 

To  one  in  the  daily  practice  of  any  department  of  surgery  a  rou- 
tine method  soon  recommends  itself  as  most  likely  to  eliminate  er- 
rors and  lead  to  a  correct  conclusion  ;  and  the  following  is  the  one 
which  has  been  adopted  by  myself. 

The  patient's  name,  age,  condition  in  life,  etc.,  are  first  entered  in 
a  case  book.  Next  he  or  she  is  urged  to  tell  the  story  of  the  disease 
in  all  its  details.  By  the  time  the  patient  has  told  the  story  the  sur- 
geon should  be  in  the  possession  of  certain  information,  and  if  not 
he  must  proceed,  by  a  few  direct  questions,  to  try  and  obtain  it. 
What  he  must  know  is  this :  How  long  has  the  patient  been  sick  ? 
Is  there  any  pain  ;  if  so,  of  what  character,  and  is  it  in  any  way  de- 
pendent upon  the  evacuation  of  the  bowels  ?  Is  there  any  protrusion 
of  the  bowels  at  stool ;  and  if  so,  what  is  its  character,  and  does  it 
return  spontaneously  or  is  it  necessary  to  replace  it  ?  Are  the  bowels 
regular,  or  is  there  diarrhoea,  and  of  what  character  ?  Is  there  any 
bleeding?  In  addition  it  must  be  discovered  whether  there  has  been 
emaciation,  febrile  action,  and  discharge  of  any  sort. 

From  such  a  verbal  examination  much  may  be  gained.  In  fact, 
the  positive  diagnosis  can  sometimes  be  made.  But,  on  the  other 
hand,  it  is  astonishing  how  often  the  most  intelligent  patient  will 
utterly  mislead  the  examiner ;  and,  though  I  have  great  confidence 
in  this  indispensable  history  as  a  prelude  to  physical  examination, 
experience  has  taught  me  nei:)er  to  trust  to  it  alone,  for  the  simple 
reason  that,  although  it  may  convey  all  the  information  necessar}^ 
the  surgeon  is  never  sure  that  he  is  not  being  unwittingly  led  upon  a 
false  track  by  the  most  intelligent  answers  his  patient  is  able  to  give. 

And  yet  an  examination  to  a  lady  is  not  a  pleasant  thing.  It  is  in 
fact  a  thing  which  will  cause  her  to  suffer  silently  for  many  years 


22  SUEGERY   OF   THE   EECTUM   AND   PELVIS. 

rather  than  submit  to  it.  It  is  only  when  suffering  has  forced  her  to 
it  that  slie  will  submit ;  but  that  point  has  always  been  reached  when 
she  consents  to  consult  a  surgeon  or  a  specialist  for  treatment.  Then 
she  expects  to  be  examined  (in  fact,  has  very  little  respect  for  the 
surgeon  if  he  does  not  examine),  and  it  remains  for  him  to  make  the 
unavoidable  examination  in  the  way  least  offensive  to  his  patient. 

For  an  ordinary  examination  of  a  lady  a  trained  female  attendant 
should  be  in  waiting.  After  the  history  has  been  taken  and  the 
physician  has  in  a  measure  gained  the  confidence  of  his  patient,  she  is 
handed  over  to  the  nurse,  who  arranges  the  patient  on  the  table,  covers 
her  with  a  sheet,  and,  when  all  is  ready,  signs  to  the  doctor.  His 
work  may  be  done  at  a  single  glance,  or  may  require  careful  investi- 
gation and  examination  with  finger  or  instruments  ;  but  when  it  is 
done  the  patient  is  again  given  over  to  the  nurse,  and  when  she  is 
once  more  herself  the  diagnosis  is  made,  and  the  question  of  treat- 
ment may  for  the  first  time  be  entered  upon. 

I  do  not  know  that  it  is  necessary  to  dilate  upon  this  point  any 
further,  except  to  say  that  in  women  the  whole  pelvis  should  always 
be  thoroughly  interrogated.  I  could  fill  a  large  volume  with  the 
histories  of  cases  of  women  suffering  from  some  palpable  disease  of 
the  uterus  or  adnexa  who  have  applied  to  me  for  supposed  rectal 
trouble.  In  fact,  if  there  is  any  disease  in  any  pelvic  organ  in  the 
male  or  female  which  may  not  cause  symptoms  referred  to  the  rec- 
tum, I  fail  at  the  moment  to  recall  it.  In  men  the  bladder  and 
prostate  may  need  careful  examination.  In  women  the  pelvic  organs 
can  be  most  satisfactorily  examined  through  the  rectum.  The  man 
who  is  equal  to  this  kind  of  work  may  fairly  be  considered  a  sur- 
geon. To  attempt  to  practise  as  a  specialist  in  diseases  of  the  rec- 
tum without  the  years  of  training  implied  by  such  work  is  to  embark 
without  compass,  rudder,  or  chart. 

For  a  rectal  examination  alone  in  male  or  female,  the  left  lateral 
position  is  the  best,  and  the  correct  Sims  position  is  not  necessary. 
Either  natural  or  artificial  light  may  be  used.  For  many  cases  there 
is  little  choice  between  the  two,  but  for  illumination  within  the 
rectal  pouch  artificial  light  has  the  advantage,  and  electric  light 
reflected  from  a  forehead  mirror  will  be  the  most  satisfactory. 

A  simple  inspection  of  the  anus  and  adjacent  skin  and  mucous 
membrane  is  often  sufficient  for  a  diagnosis,  though  it  should  never 
be  trusted  to  alone.  External  hemorrhoids,  and  internal  ones  when 
brought  down  by  the  use  of  the  closet  or  enema,  external  fistulse, 


GENERAL   RULES   REGARDHSTG   EXAMINATION   AND   DIAGNOSIS.      23 

ulceration,  skin  diseases,  many  venereal  affections,  pin-worms,  ab- 
scess, and  fissure,  may  all  be  recognized  in  tliis  way.  A  glance  at 
tlie  anus,  too,  may  indicate  to  the  practised  eye  the  existence  of 
serious  disease  within  the  rectum  proper,  for  a  discharge  may  flow 
from  it  which  marks  ulceration  above,  and  it  may  be  relaxed  and 
patulous  from  qj^erdistention  or  partial  destruction  of  the  sphincter. 
By  using  gentle  force  in  pulling  the  anus  open  with  the  fingers, 
the  mucous  membrane  may  be  everted   to  a  considerable  degree, 


Fig.  13. — Bimanual  Pelvic  Examination  per  Rectum. 


especially  if  the  patient  can  be  brought  to  assist  by  an  effort  at 
bearing  down.  In  this  way  a  fissure  may  almost  always  be  brought 
into  view  without  the  use  of  a  speculum  of  any  sort,  and  a  good 
view  of  the  radiating  folds  and  lacunge  may  be  obtained. 

It  may  or  may  not  be  necessary  to  give  an  enema  to  any  par- 
ticular patient,  but  it  should  always  be  at  hand  if  the  diagnosis  is 
not  clear  without  it.  There  are  three  classes  of  cases  in  which  it  is 
indispensable— those  in  which  a  protrusion  is  caused  at  stool  which 
cannot  be  produced  at  will  with  the  patient  on  the  table  ;  those  in 
which  the  rectum  is  so  filled  with  fseces  that  no  examination  is  of 


24  SUEGERY   OF   THE   RECTUM   AND   PELVIS. 

any  value  ;  and  those  in  which  it  is  desirable  to  make  a  visual  ex- 
amination very  high  up  or  to  pass  the  rectal  sound. 

Suppose  that  the  enema  has  been  given,  the  patient  is  in  position 
and  there  is  no  protrusion,  no  opening  of  a  fistula,  no  fissure  just 
within  the  anus,  and  no  capillary  hemorrhoid.  In  fact,  no  disease 
is  manifest. 

The  next  step  is  the  digital  examination  of  the  rectum.  With  the 
patient  on  the  left  side,  the  right  index  finger  should  be  used  to  ex- 
amine the  posterior  wall,  and  the  left  for  the  anterior  wall,  so  that 
the  whole  rectum  may  be  felt  by  the  palmar  surface  of  the  finger. 

The  condition  of  the  sphincter  muscle  is  first  to  be  noted.  Its  re- 
sistance should  be  overcome  by  a  slow  and  steady  pressure  with  the 
ball  of  the  finger,  and  not  by  a  sudden  exertion  of  force,  for  such  an 
attack  is  always  met  by  increased  contraction.  The  force  of  the 
muscle  will  be  found  to  vary  greatly  in  different  people.  In  the 
aged  or  debilitated  it  is  lax  ;  in  the  strong  and  healthy  it  is  the  op- 
posite, and  the  finger  can  scarcely  be  passed  through  it  without  pain 
and  sometimes  a  slight  laceration  of  the  tender  mucous  membrane. 
When  inclined  to  spasmodic  contraction,  as  it  sometimes  is  in  per- 
sons of  nervous  tendency,  a  satisfactory  examination  may  be  im- 
possible without  the  use  of  ether,  on  account  of  the  pain. 

Unless  an  obstruction  is  encountered,  the  finger  may  be  carried 
up  the  bowel  its  full  length,  and  pressed  as  far  as  possible  beyond 
this  point.  Additional  distance  may  be  gained  by  passing  the  three 
remaining  fingers  backward  along  the  inter-gluteal  groove,  instead  of 
closing  them  in  the  palm  as  is  generally  done,  and  pressing  the 
knuckles  against  the  soft  parts  ;  for  the  knuckles  prevent  the  full 
passage  of  the  index  finger. 

In  this  way  three  and  a  half  or  four  inches  of  the  rectum  may  be 
carefully  explored,  together  with  the  prostate,  the  neck  of  the  blad- 
der, the  uterus,  the  anterior  surface  of  the  coccyx  and  lower  part 
of  the  sacrum,  the  ovaries,  broad  ligaments,  and  tubes,  the  vesiculge 
seminales,  and  vasa  deferentia.  In  other  words,  all  that  part  of  the 
bowel  which  is  most  subject  to  disease  is  brought  within  reach.  But 
after  this  is  done  the  examiner  may  be  no  wiser  than  before,  and  to 
appreciate  fully  the  condition  of  the  rectum  by  the  sense  of  touch 
alone  requires  a  facility  of  exploration  which  most  practitioners  never 
attain.  In  the  majority  of  cases  a  digital  examination  will  be  made 
to  discover  whether  or  not  the  patient  is  suffering  from  internal 
hemorrhoids  ;   and  in  the  majority  of  cases  also  the  examiner  will  be 


GEjSTERAL   rules   REGARDIlSrG   EXAMINATION   AND   DIAGNOSIS.      25 

no  wiser  on  this  point  after  than  before,  for  a  soft  internal  hemorrhoid 
is  a  difficult  thing  to  detect  by  the  finger  alone,  being  readily  mis- 
taken for  the  natural  mucous  membrane  of  the  part,  especially  when 
the  latter  is  abundant  and  gathered  into  folds,  as  it  is  apt  to  be. 

Ulceration  is  another  condition  which  it  is  sometimes  difficult  to 


Fig.  14.— Leg  Supporters  Attached  to  Table. 

detect,  especially  when  superficial  and  not  attended  by  much  indura- 
tion ;  and  so  is  the  opening  of  a  blind  internal  fistula  ;  and  yet,  so 
well  educated  may  the  finger  become  that  other  methods  of  exami- 
nation may  be  almost  completely  discarded.  To  carry  diagnosis  to 
this  point  it  is  first  necessary,  by  oft-repeated  examinations,  to  be- 
come perfectly  familiar  with  the  feel  of  the  normal  bowel.     After  this 


26 


SURGEEY   OF   THE   RECTUM   AND   PELVIS. 


knowledge  has  been  gained,  a  gentle  sweeping  of  the  ball  of  the  finger 
over  the  whole  inner  surface  of  the  lower  three  inches  of  the  rectum 
will  detect  any  change  in  it,  however  slight. 

A  stricture  of  small  calibre  cannot  easily  be  mistaken,  though  one 
which  admits  the  finger  without  constricting  it  may  easily  be  over- 


FiG.  15. — Leg  Supporters  Attached  to  Bed. 


looked.  A  stricture  small  enough  to  engage  the  end  of  the  index 
finger  firmly,  marks  the  limit  of  safe  digital  examination,  and  the 
finger  should  not  be  forced  through  it  for  the  sake  of  feeling  what  is 
above,  for  an  attempt  to  do  this  may  be  followed  by  fetal  rupture. 

The  next  step  in  the  examination  of  women,  should  the  diagnosis 
still  be  obscure,  is  bimanual   exploration  of  the  pelvis  by  means  of 


GENERxiL   KULES   REGARDING   EXAMINATION   AND   DIAGNOSIS.      27 


one  finger  in  the  rectum.  For  this  I  cannot  too  strongly  recommend 
the  upright  supports  of  Edebohls  shown  in  the  cut.  By  their  use 
the  abdominal  muscles  are  as  much  relaxed  as  it  is  possible  to  get 
them  without  the  use  of  an  anaesthetic,  and  the  patient  is  in  the 
most  favorable  position  for  examination.     Figs.  14  and  15. 

Should  even  this  be  unsuccessful  the  examiner  still  may  have 
recourse  to  an  anaesthetic,  and  for  this  the  patient  should  be  in  the 
same  position. 

For  examination  by  the  sense  of  touch  above  the  reach  of  the 
finger,   recourse  may  be  had  to  bougies.      Of  these  there  are  two 


Fig.  16— Soft  Bougie. 

forms  which  are  of  value.  One  is  the  red,  soft-rubber  instrument 
with  tapering  and  slightly  bulbous  point,  shown  in  Fig.  16.  This  is 
made  in  twelve  sizes,  and  for  diagnosis  a  No.  7  is  about  the  best. 
They  are  perforated  to  allow  of  the  injection  of  water  through  them. 
Another  useful  form  of  instrument  is  shown  in  Fig.  17.  It  is  a 
sound  for  which  the  profession  is  indebted  to  Dr.   Andrews,  and 


Pig.  17. — Andrews'  Sound 

which,  after  many  trials,  I  have  found  better  adapted  for  diagnosis 
than  any  of  the  instruments  with  flexible  shanks.  It  is  based  on  the 
principle  that  the  rectum  can  be  sounded  by  an  inflexible  instrument 
of  proper  curve,  exactly  as  the  urethra  can  be  with  Van  Buren's 
sound,  and  it  is  used  in  the  same  way.  It  is  a  more  difficult  instru- 
ment to  pass  than  the  urethral  sound,  and  is  not  to  be  recommended 


28  SURGERY    OF   THE    RECTUM    AKD    PKLVIS, 

to  beginners  ;  but  with  care,  gentleness,  and  skill  it  is  most  satis- 
factory. It  is  of  hard  metal  and  fitted  with  tips  of  various  sizes.  It 
is  fourteen  inches  long  ;  but  it  does  not  explore  the  same  number  of 
inches  of  gut,  for  the  reason  that  when  the  tip  reaches  the  movable 
part  of  the  sigmoid  flexure,  eight  or  ten  inches  from  the  anus,  it  no 
longer  slides  along  the  bowel,  but  carries  the  bowel  along  with  it  till 
the  tip  can  be  seen  to  impinge  against  the  abdominal  wall  generally 
a  little  to  the  right  of  the  umbilicus.  For  examination  of  the  ujDper 
rectum  and  lower  sigmoid  flexure,  however,  it  is  much  better  in  my 
hands  than  any  similar  instrument  with  a  flexible  handle  supposed 
to  follow  the  natural  curves  of  the  canal.  Dr.  Andrews'  model  is 
all  metal,  but  for  lightness  I  have  substituted  hard-rubber  bulbs. 

The  old-fashioned  red,  hard-rubber  bougie  is  unnecessarily  stiff 
and  dangerous,  and  should  be  discarded,  having  no  advantages  over 
the  softer  ones  either  for  the  purpose  of  diagnosis  or  for  that  of  treat- 
ment. The  better  fitted  a  bougie  is  for  allowing  the  use  of  force  the 
more  dangerous  it  is. 

These  instruments  are  all  used  for  the  same  purpose — that  of 
feeling  for  a  stricture  located  above  the  reach  of  the  finger  ;  and  with 
any  of  them  the  unpractised  hand  will  generally  detect  an  obstruction 
in  the  perfectly  healthy  bowel  at  about  four  inches  from  the  anus.  I 
have  had  patients  in  whom  I  have  never  been  able  to  pass  any  sort 
of  a  bougie  without  first  injecting  the  rectum,  no  matter  what 
manoeuvring  I  resorted  to  ;  and  I  have  seldom  told  a  student  to  pass 
a  rectal  bougie  that  he  did  not  at  once  discover  a  stricture.  To  pass 
a  bougie  into  the  rectum  is  rather  a  more  difiicult  operation  than  to 
pass  one  into  the  urethra,  the  triangular  ligament  in  the  latter  being 
replaced  by  the  curves,  the  folds  of  mucous  membrane,  and  the  pro- 
montory of  the  sacrum  in  the  former.  Independent  of  Houston's 
valves  of  mucous  membrane,  it  is  not  improbable  that  a  slight  degree 
of  invagination  of  the  upper  into  the  lower  part  of  the  rectum  may 
often  be  produced  by  pressure  of  the  end  of  a  bougie  from  below 
upward,  and  into  the  sulcus  thus  formed  the  point  of  the  bougie  may 
easily  pass.  For  the  sake  of  overcoming  these  folds  of  membrane, 
the  most  minute  directions  have  been  given  as  to  how  the  bougie 
should  be  introduced  and  gently  urged  along  each  successive  inch  of 
the  bowel  by  changing  its  direction  and  manipulating  the  handle. 
But  such  rules  are  of  little  value,  for  the  simple  reason  that  the 
obstruction  is  seldom  of  the  same  kind  or  in  the  same  place  in  two 
different  persons.     The  instrument  should  be  passed  gently,  for  force 


GENERAL    RULES    REGARDING    EXAMINATION    AND    DIAGNOSIS. 


29 


is  never  allowable  here  more  than  in  the  similar  operation  on  the 
urethra  ;  and  when  an  obstruction  is  met  with,  the  handle  should  be 
gently  rotated,  withdrawn,  and  again  passed  onward  till  by  frequent 
repetitions  of  this  manoeuvre  it  is  made  to  pass. 

Before  attempting  to  pass  any  form  of  bougie  the  upper  bowel 
should  be  gently  distended  with  as  much  warm  water  as  can  easily 
be  retained.  By  this  simple  manoeuvre  the  normally  closed  canal  is 
changed  into  a  smooth  cylinder,  the  obstructing  folds  of  mucous 
membrane  are  removed,  and  the  only  obstacle  remaining  is  the  pro- 
montory of  the  sacrum. 

For  the  purposes  of  exact  clinical  study  and  report,  a  scale  such  as 
is  shown  in  the  cut  (Fig.  18)  should  always  be  at  hand  for  measuring 
rectal  bougies. 

I  have  been  using  for  some  time  a  set  of  bougies  exactly  similar 
in  make  to  the  soft-rubber  ones,  but  six  instead  of  twelve  inches  in 


Fig.    18.— Scale  of  Bougies. 

length.  They  are  not  adapted  for  diagnosis,  but  for  the  patient's 
own  use  when  prolonged  dilatation  is  necessary,  and  I  only  speak  of 
them  in  this  connection  to  avoid  confusion. 

In  case  disease  actually  exists  high  up  in  the  bowel,  the  attempt 
to  pass  an  instrument  is  full  of  danger.  A  patient  may  easily  recover 
from  a  false  passage  made  in  the  urethra,  but  such  will  seldom  be  the 
Case  with  the  rectum,  for  here  when  the  instrument  leaves  the  bowel 
it  enters  the  peritoneum.  To  understand  this  danger  it  is  only  neces- 
sary to  remember  that  the  bowel  is  generally  ulcerated  both  above 
and  below  the  seat  of  a  constriction,  and  is  sometimes  weakened  to 
such  an  extent  that  it  will  allow  a  bougie  to  pass  through  it  without 
the  use  of  any  appreciable  force  on  the  part  of  the  surgeon.  The 
bowel  may  also  be  lacerated  without  being  directly  perforated  by  the 
bougie,  for  the  stricture  may  be  pushed  upward  or  dragged  downward 
on  the  j)oint  of  the  instrument  till  the  bowel  gives  way. 

Supposing,  now,  that  a  rectal  bougie  cannot  be  passed  eight  or 


30  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

ten  inches  up  the  bowel,  is  it  safe  on  this  account  alone  to  make  a 
diagnosis  of  stricture  high  up  ?  I  should  hesitate  long  before  doing 
so,  and  should  make  many  careful  attempts  to  pass  the  instrument 
at  different  times,  carefully  exploring  through  the  abdominal  wall 
for  induration,  and  watching  for  the  usual  signs  of  obstruction. 
There  are  one  or  two  points  worthy  of  remembrance  in  this  connec- 
tion. The  first  is  that  the  obstruction  due  to  a  stricture  will  always 
be  at  the  same  point  in  the  canal ;  and  another  is  that  when  a  bougie 
has  once  become  engaged  in  a  stricture  it  is  firmly  grasped,  and  the 
resistance  to  its  withdrawal  is  equal  to  that  encountered  in  intro- 
ducing it  farther.  The  feeling  conveyed  to  the  hand  under  these 
ch'cum stances  is  diagnostic,  and  is  like  that  which  is  felt  when  the 
effort  is  made  to  withdraw  a  sound  from  the  grasp  of  a  stricture  in 
the  urethra. 

And  yet  the  value  of  this  means  of  exploration  is  very  great,  and 
although  a  bougie  may  pass  a  stricture  without  detecting  it,  succes- 
sive failures  to  get  an  instrument  through  into  the  sigmoid  flexure 
w^ould,  in  my  own  practice,  lead  me  to  diagnosticate  an  obstruction. 

Let  us  suppose  once  again,  that  all  this  has  been  done  and  yet 
the  examiner  has  discovered  no  disease.  At  this  point  he  must  take 
a  decided  responsibilitj^,  for  if,  from  the  patient's  histor}^,  he  believes 
that  disease  actually  exists,  he  must  still  go  on  and  find  it ;  but  if  he 
has  no  reason  to  believe  this,  he  may  abandon  the  search  at  this 
point  and  commit  himself  to  the  opinion  that  there  is  no  physical 
lesion. 

If  he  decides  to  go  still  farther,  there  is  but  one  line  of  investiga- 
tion to  be  followed,  and  this  consists  in  the  administration  of  ether, 
and  possibly  the  dilatation  of  the  sphincter,  and  the  use  of  the  spec- 
ulum. Should  these  fail,  nothing  remains  but  an  exploratory  lapa- 
rotomy. 

It  will  be  noticed  that  up  to  this  time  the  question,  "What  spec- 
ulum do  you  use?  has  not  been  answered,  and  for  the  reason  that  up 
to  this  point  in  the  examination  I  use  no  speculum  ;  and  as  the  vast 
majority  of  examinations  will  lead  to  a  diagnosis  before  this  point  is 
reached,  it  follows  that  in  about  ninety  per  cent,  of  all  cases  I  use  no 
speculum  at  all. 

An  entirely  too  exalted  idea  of  the  value  of  the  speculum  exists. 
For  ordinary  examinations  it  is  unnecessary,  and  the  diseases  which 
cannot  be  detected  by  the  routine  practice  already  described  will  not 
very  often  be  detected  by  the  simple  use  of  any  variety  of  this  in- 


GENERAL   RULES   REGARDING   EXAMINATION   AND   DIAGNOSIS. 


31 


strument.  So  strongly  lias  this  experience  been  impressed  upon  me 
that  I  have  abandoned  the  use  of  eveiy  form  of  speculum  for  ordi- 
nary diagnostic  purposes,  unless  at  the  same  time  its  auxiliary 
means  can  be  employed — the  administration  of  ether.  With  ether,  a 
light,  and  a  speculum,  a  diagnosis  may  often  be  made  which  would 


Pig.  19. — Sims'  Rectal  Speculum. 

otherwise  be  impossible  ;  but  to  use  a  speculum  without  ether,  for 
the  purpose  of  exploring  the  rectal  pouch,  is  merely,  in  the  vast  ma- 
jority of  cases,  to  inflict  useless  suffering. 

This  does  not  apply  to  the  question  of  treatment,  but  simply  to 
diagnosis.  For  there  exists  a  certain  class  of  diseases,  notably 
ulcers,  which,  when  their  situation  is  accurately  known,   can  be 


Fig.  20.— Author's  Speculum. 

brought  into  the  field  of  vision  by  a  speculum  and  thus  treated  by 
direct  applications  ;  but  this  is  a  very  different  matter  from  taking  a 
patient  who  complains,  perhaps,  of  but  the  single  symptom  of  rectal 
pain,  introducing  some  variety  of  speculum  by  which  only  the  most 
imperfect  view  can  be  obtained,  and,  because  nothing  is  discovered 


32  SUEGERT   OF   THE   RECTUM   AND   PELVIS. 

(as  in  the  vast  majority  of  cases  nothing  will  be),  pronouncing  the 
patient  free  from  disease. 

Should  a  speculum  seem  necessary  there  is  an  infinite  number  to 
choose  from.  The  best  of  all  when  ether  is  used  is  the  one  shown  in 
Fig.  19.  For  the  purpose  of  local  applications  without  ether,  and 
after  a  diagnosis  has  been  made,  I  use  either  the  one  shown  in  Fig.  20, 
or  the  Aloe  instrument  (Fig.  21),  made  fully  an  inch  longer  than  the 


Fig.  21. — Aloe  Speculum. 

original.  A  medium-sized  blade  of  Sims'  vaginal  speculum  answers 
every  purpose,  though  Van  Buren's  modification  has  a  great  advan- 
tage, the  notch  allowing  a  very  much  larger  surface  of  the  bowel  to 
come  into  view. 

By  the  use  of  the  very  long  straight  cylindrical  specula  shown 
in  Figs.  22  and  23  and  a  forehead  mirror,  it  is  unquestionably  possi- 
ble, with  a  patient  as  shown  in  Fig.  24,  to  see  much  farther  into  the 
rectum  and  sigmoid  flexure  than  has  usually  been  supposed. 

For  the  knowledge  of  this  fact  we  are  indebted  to  Kelly,  and  I  do 
not  hesitate  to  acknowledge  its  great  value.  By  these  instruments  I 
have  not  only  diagnosticated  the  exact  seat  of  a  circumscribed  ulcer- 
ation and  polypoid  growths  very  high  in  the  rectum,  but  have  cured 
the  same  by  local  applications  and  removal  in  cases  certainly  other- 
wise incurable  except  possibly  by  colostomy.  The  great  objection 
to  Kelly's  instrument  is,  however,  the  small  extent  of  rectum  brought 
into  the  field  of  vision  at  any  one  time.  I  have  had  much  more  satis- 
faction with  an  Aloe  speculum  of  equal  length  made  for  this  express 
purpose. 

The  stretching  of  the  sphincter  is  in  itself  an  almost  entirely 
harmless  proceeding,  but  one  which  necessitates  the  previous  admin- 
istration of  ether.  It  should  not,  however,  be  done,  as  was  at  one 
time  the  usual  method,  and  as  it  is  often  done  at  present,  by  intro- 
ducing the  thumbs  back  to  back,  and  forcibly  and  suddenly  sepai-at- 


GENERAL   RULES   REGARDING   EXAMINATION"   AND   DIAGNOSIS.      'S'6 

ing  them  till  they  touch  the  tuberosities  on  each  side.  A  better  way 
is  to  introduce  first  one  finger,  then  two,  and  finally  four  in  the  form 
of  a  funnel,  and  gradually  bore  into  the  anus  ;  or  to  introduce  two 
fingers  and  make  pressure  on  all  sides  of  the  opening  till  it  becomes 
patulous.  Instead  of  one  or  two  seconds,  this  procedure  should 
occupy  five  minutes,  and  should  be  done  so  gently  as  not  to  lacerate 
the  mucous  membrane.  The  dilatation  should  also  be  made  to  in- 
clude the  internal  as  well  as  the  external  muscle.  If  this  dilatation 
be  carried  to  a  sufficient  extent,  the  firm,  cord-like  feel  of  the  exter- 
nal sphincter  may  be  made  to  completely  disappear.  The  paralysis 
induced  in  this  way  is  always  temporary,  and  I  have  never  known  it 


I        1 


Pig.  22.— Kelly's  Speculum. 


Fig.  23. — Kelly's  Speculum. 


to  be  followed  even  by  a  temporary  incontinence  of  faeces.  After 
coming  out  of  the  ether  the  patients  are  usually  conscious  of  only  a 
sense  of  soreness  in  the  part,  but  are  never  incapacitated  for  their 
usual  duties.  This  stretching  of  the  sphincters  is  a  necessary  pre- 
liminary in  almost  all  operations  within  the  rectum. 

From  what  has  been  said  it  may  readilj^  be  seen  that  the  diagnosis 
of  stricture  above  the  reach  of  touch  or  vision  is  a  difficult  matter. 

3 


34 


SURGERY    OF    THE    RECTUM    A^D    PELVIS. 


FiQ.  24. — Position  for  High  Rectal  Exploration. 


GENERAL    RULES    REGAKDHSTG   EXAMINATION    AND    DIAGNOSIS.       35 

In  reality  strictures  above  the  rectal  i:)oucli  are  rare  ;  and  when  they 
exist  they  are  usually  malignant,  for  this  part  of  the  bowel  is  free 
from  many  of  the  influences  which,  by  exciting  ulcerative  action, 
result  in  the  cicatricial  contractions  which  so  often  affect  the  lower 
three  inches  of  the  rectum. 

After  the  use  of  the  bougie,  which  is  at  best  an  uncertain  means 
of  diagnosis  for  this  condition,  and  after  a  study  of  the  symptomatol- 
ogy and  a  careful  examination  through  the  abdominal  wall,  there  is 
but  one  means  left  for  diagnosis,  and  that  consists  in  exploratory 
laparotomy.     Examination  by  introducing  the  whole  hand  into  the 


Fig.  35  — High  Exploration. 

rectum  is  so  much  more  dangerous  than  laparotomy  that  its  future 
employment  may  be  abandoned. 

I  can  add  nothing  more  to  what  has  already  been  said  on  this 
point,  except  that  the  man  who  has  foolishly  allowed  himself  to  be 
beguiled  into  prescribing  some  salve  for  a  cancer,  when  he  thinks  he 
is  treating  hemorrhoids,  because  his  patient  objects  to  an  examina- 
tion, need  not  feel  hurt  when  he  finds  himself  placed  in  a  ridiculous 
light  by  some  better  man  tlian  himself  who  has  made  his  diagnosis 
before  beginning  treatment.  All  his  tender  regards  for  the  foolish 
susceptibilities  of  his  nervous  lady  patient  will  bring  him  no  mercy 
in  her  judgment.  She  is  willing  to  admit  that  she  may  have  been 
foolish,  but  she  will  make  no  allowance  for  the  foolishness  of  her 
physician,  and  in  fact  he  deserves  none. 

There  are  but  three  ways  of  making  a  diagnosis — by  question,  by 
sight,  by  touch.  The  man  who  has  exhausted  these  will  seldom  fail, 
and,  should  he  do  so,  need  not  be  ashamed.  The  man  who  neglects 
any  one  of  them  will  sooner  or  later  make  some  error  which  he  might 
easily  have  avoided. 


CHAPTER  III. 

GENERAL  RULES  REGARDING  OPERATIONS. 

In  no  branch  of  surgery  is  antisepsis  so  difficult  to  establish  and 
asepsis  so  difficult  to  maintain  as  in  the  surgery  of  the  alimentary 
canal.  The  mucous  membrane  is  exceedingly  difficult  to  clean,  the 
colon  bacillus  is  always  present,  and  is  probably  the  most  common 
cause  of  suppuration  and  peritonitis,  after  operations  upon  it ;  and 
in  addition  we  have  all  the  other  micro-organisms  which  are  to  be 
avoided  in  any  branch  of  surger}^ 

It  is  quite  true  that  in  two  or  three  of  the  minor  operations  on 
the  rectum,  such  as  piles  and  fistula,  even  if  no  effort  is  made  to 
avoid  suppuration,  and  we  do  not  seek  for  union  by  first  intention, 
our  patients  recover  without  accident  and  without  detriment  except 
loss  of  time.  In  these  operations  ordinary  cleanliness  as  to  hands 
and  instruments,  and  the  avoidance  of  any  direct  introduction  of 
septic  matter  seem  all  sufficient  to  avoid  grave  complications.  But 
here  the  list  ends  absolute]}^,  and  as  we  enter  the  more  serious  work 
of  intestinal  and  abdominal  surgery  absolute  asepsis  becomes  simply 
a  matter  of  life  or  death  to  the  patient. 

The  operator  who  pays  no  attention  to  asepsis  in  a  minor  opera- 
tion will  find  it  very  difficult  to  practise  it  in  a  major  one  ;  for 
technique  in  surgery  becomes  second  nature,  and  only  constant 
study  and  attention  will  render  it  perfect.  Whereas  the  surgeon 
whose  hands  and  instruments  are  always  sterile  before  touching  his 
patient,  will  be  as  clean  in  a  hemorrhoid  case  as  in  a  laparotomy, 
although  the  after-dressings  and  management^  of  the  wound  may  be 
totally  different. 

Laying  aside  all  theories,  the  best  practical  rule  for  an  operator  to 
be  governed  by  is  that  not  only  he,  but  his  patient,  and  everything 
that  comes  in  contact  with  himself,  or  his  patient,  or  the  wound, 
directly  or  indirectly,  is  septic  until  rendered  aseptic  by  artificial 
means.     These  means  are  either  the  use  of  chemicals,  as  bichloride  of 


GENEEAL   RULES    REGARDING   OPERATIONS.  37 

mercury,  mechanical  scrubbing  and  wasliing  with  strong  soaps,  or 
the  application  of  steam  or  dry  heat.  Because  of  the  labor  and  care 
necessary  to  insure  perfect  asepsis  most  men  at  present  prefer  to  do 
their  operating  in  hospital  operating-rooms,  where  all  the  facilities 
are  at  hand,  and  with  a  corps  of  trained  assistants  especially  edu- 
cated in  this  work.  There  is  no  detail  of  antisepsis,  however,  which 
cannot  be  perfectly  carried  out  in  any  private  house  with  sufficient 
care  and  trouble.  Most  of  my  own  major  surgery  is  done  in  the  per- 
fectly appointed  operating-theatre  of  the  New  York  Post-Graduate 
Hospital,  but  by  no  means  all  of  it  ;  and  when  once  the  theory  of 
cleanliness  has  been  thoroughly  grasped  any  practitioner  will  be 
able  to  do  an  abdominal  section,  should  emergency  demand  it, 
with  as  faultless  a  technique  as  in  the  best  appointed  hospital,  if  he 
understands  what  asepsis  implies,  and  is  willing  to  devote  the  neces- 
sary time  and  trouble  to  securing  it. 

Preparing  the  Patient. — The  patient  is  best  sterilized  by  first 
taking  a  general  bath  in  hot  water  with  green  soap  a  few  hours  be- 
fore the  operation.  This  is  the  only  part  that  should  be  left  to  the 
management  of  any  nurse.  The  field  of  operation  should  always  be 
attended  to  by  the  surgeon  at  the  time  of  operation  if  he  wishes  to 
be  sure  of  his  results.  By  this  rule  all  the  annoying  preparations 
for  operation  to  which  the  patient  is  subjected  for  days  before  the 
event,  and  which  have  a  depressing  mental  effect  ;  such  as  packing 
the  vagina  several  times  with  iodoform  gauze  ;  scrubbing  the  abd,o- 
men  and  poulticing  the  site  of  the  incision  with  soap,  are  avoided. 
When  the  patient,  in  a  clean  night-gown,  after  the  bath,  is  under 
ether  upon  the  operating-table,  all  final  preparations  may  be  made 
in  a  few  moments  under  the  eye  of  the  operator. 

The  Surgeon  and  Assistants. — The  surgeon  and  all  assistants  who 
are  to  handle  instruments  or  sponges — in  other  words  all  who  come 
in  immediate  contact  with  anything  which  may  touch  the  wound  or 
adjacent  parts — should  submit  to  the  following  preparations. 

The  hands  and  arras  up  to  the  elbows  should  be  scrubbed  for  five 
minutes  with  green  soap,  hot  water,  and  a  nail-brush  which  has  been 
recently  boiled  and  is  kept  in  a  solution  of  bichloride  1  to  1,000. 
Special  attention  should  be  given  to  the  nails,  and  after  the  scrubbing 
they  should  be  carefully  cleaned  with  knife  or  nail -cleaner  which  is 
also  sterile  and  kejDt  for  that  purpose.  Rings  should  be  removed  and 
nails  pared  moderately  short.  The  best  nail-cleaner  is  a  sharpened 
stick  of  olive  wood. 


38  SURGERY    OF    THE    RECTU.^l    AND    PELVIS. 

Nurses  who  are  to  assist  around  the  operating- table  in  handling 
sponges,  the  cautery,  etc.,  will  usually  be  safe  if  after  this  scrubbing 
of  the  hands  and  arms  they  are  completely  covered  with  a  white 
gown,  buttoned  behind,  which  conceals  all  of  their  other  clothing 
and  which  has  been  freshly  rendered  sterile  by  being  thoroughlj- 
steamed  for  half  an  hour.  The  hands  and  arms  should  finally  be 
soaked  for  five  minutes  in  bichloride  1  to  1,000,  and  the  nurses  may 
be  considered  fit  for  their  work. 

Even  the  operator  and  the  assistant  who  is  to  handle  instruments 
will  do  fairly  well  with  this  preparation,  but  more  is  desirable  where 
the  facilities  permit.  After  the  preliminary  scrubbing  already  de- 
scribed, the  surgeons  should  remove  their  clothing  down  to  their 
undej-clothes  and  put  on  white  duck  or  heavy  linen  trousers  and 
jackets,  the  sleeves  of  which  reach  only  to  the  middle  of  the  arm 
and  leave  the  elbow  bare.  A  second  scrubbing  with  soap  and  clean- 
ing of  the  nails  is  then  absolutelj^  necessary,  and  a  final  immersion 
of  hands  and  forearms  in  bichloride  1  to  1,000,  for  five  minutes. 

Instead  of  bichloride  solution  for  the  hands  many  prefer  a  wash 
of  permanganate  of  potash  (hot,  saturated  solution)  to  be  removed 
with  a  hot  saturated  solution  of  oxalic  acid,  which  in  its  turn  should 
be  washed  off  with  hot  water.  This  may  easily  be  done  in  hospital, 
but  in  private  the  bichloride  is  easier,  and  I  believe  it  to  be  equally 
efficient.     At  least  I  have  found  it  so. 

The  most  frequent  errors  in  technique  come  from  touching  things 
which  have  not  been  sterilized  after  all  these  preparations  have  been 
made.  In  the  excitement  of  the  operation,  or  from  ignorance  or 
carelessness,  a  bottle  is  grasped  which  though  it  may  hold  sterilized 
catgut  is  not  itself  sterile  outside  ;  or  gauze  is  wanted  from  a  glass 
jar  the  outside  of  which  is  not  sterile,  and  the  person  who  has  handled 
the  jar  is  no  longer  clean,  and  should  leave  the  operating  field,  and 
again  scrub  his  hands.  A  special  assistant  should  always  be  at 
hand  for  just  such  calls  as  this.  He  or  she  is  not  supposed  to  be 
sterilized  or  to  come  into  contact  with  anything  to  aching  the  wound, 
and  it  is  his  or  her  particnlar  work  to  uncork  bottles,  change  basins, 
handle  pitchers  of  hot  water,  raise  or  lower  the  operating-table,  etc., 
but  never  to  touch  anything  which  is  to  come  in  contact  with  the 
field  of  operation. 

Instruments. — All  these  except  knives  are  best  sterilized  by  boil- 
ing in  a  one  per  cent,  solution  of  washing-soda  fifteen  minutes  before 
each  operation.     If  this  is  done  in  a  large,  shallow,  porcelain-lined 


GENERAL  RULES  REGARDING  OPERATIONS.  '69 

dish,  which  is  covered  by  another  of  the  same  size,  the  two  dislies 
may  be  placed  directly  on  the  instrument  table,  from  the  gas-burner 
or  stove  upon  which  they  have  been  boiled,  without  changing  tliem. 
When  the  dish  forming  the  cover  is  taken  off  and  turned  down,  two 
perfectly  sterile  dislies  are  at  hand.  A  third,  preferably  of  glass, 
which  has  been  previously  placed  in  boiling  water,  to  hold  needles 
and  sutures,  will  usually  suffice  for  any  operation. 

If  the  knives  be  subjected  to  this  boiling,  the  edge  will  quickl}" 
be  taken  off.  A  better  plan  is  to  immerse  first  the  handle,  and  then 
the  blade  in  pure  carbolic  acid,  wash  off  the  acid  with  sterilized 
water,  and  lay  the  knife  on  the  instrument- table  ready  for  use. 

Ligatures  and  Sutures. — Catgut,  silk-worm  gut,  silk,  horse- 
liair,  and  kangaroo  tendon  for  ligatures  or  sutures  can  now  be  bought 
in  convenient  form,  and  reliably  prepared  from  almost  any  surgical 
instrument  maker  and  many  druggists.  Kangaroo  tendon  is  used 
almost  exclusively  for  hernia  operations.  Silk-worm  gut  may  be 
purchased  in  bundles,  and  sterilized  by  boiling  with  the  instruments 
at  the  time  of  operation.  The  same  applies  to  silk,  which  should 
be  wound  on  glass  spools,  and  may  be  either  kept  sterile  in  a  jar  till 
needed,  or  freshly  boiled  with  the  instruments  at  the  time  of  oper- 
ation. Catgut  may  be  bought  already  prepared,  though  for  a  sur- 
geon with  large  practice  it  is  much  cheaper  to  buy  it  in  large  quan- 
tities and  prepare  it  himself.  Much  elaborate  preparation  has  been 
indulged  in  to  render  catgut  sterile.     My  own  plan  is  very  simple. 

From  any  dealer  buy  such  sizes  and  quantities  of  gut  as  are  de- 
sired. It  is  best  to  select  it  personally,  for  numbers  of  sizes  vary  so 
as  to  be  no  guide.  Buy  what  is  known  as  "bow-lines,"  which  are 
cut  to  the  standard  length  of  one  metre,  coiled,  and  tied  separatel}^ 
A  certain  number  of  these  strings,  depending  on  the  size,  form  a 
bundle  which  is  tied  round  by  a  separate  piece  of  gut  and  sold  in 
that  form.  The  number  of  bow-lines  in  a  bundle  will  vary  from  one 
dozen  to  six  dozen,  depending  on  the  size  of  the  gut.  To  prepare  for 
use  simply  drop  the  whole  bundle,  still  bound  together,  into  a  covered 
jar  containing  commercial  ether.  Leave  in  this  any  convenient  length 
of  time,  from  two  days  to  weeks,  pour  off  the  ether  which  will  have 
removed  the  fatty  matter  and  replace  it  by  a  solution  of  alcohol  and 
bichloride  1  to  3,000.  After  standing  in  this  solution  for  a  few  days 
the  gut  is  fit  for  use.  As  the  strings  are  only  one  metre  long,  when 
one  has  once  been  removed  from  the  solution  during  an  operation  it 
should  never  be  returned  to  the  bottle.     In  this  wiiy  the  bottle  will 


40 


STJRGEEY    or   THE    RECTUM    A^'D    PELVIS. 


remain  sterile  indefinitely,  although  I  am  in  the  habit  of  occasionally 
changing  the  solution  for  security,  and  the  bichloride  will  after  a 
time  weaken  the  gut. 

The  tensile  strength  of  catgut  and  its  power  of  resisting  absorp- 
tion, but  especially  the  latter,  may  be  greatly  increased  by  soaking 
it  for  a  time  in  a  solution  of  bichromate  of  potash.  A  formula  for 
the  solution  is  bichromate  of  potash  fifteen  grains,  water  one  ounce, 


Fig.  26. — Sealed  before  Sterilizinc 


alcohol  fifteen  ounces.  The  gut.  after  previous  preparation  as  de- 
scribed, should  be  left  in  this  for  fifteen  hours  and  then  placed  again 
in  alcohol,  or  in  bichloride  alcohol  as  may  be  prefen-ed.  By  care  and 
exactness  in  the  use  of  the  potash  gut  ma}^  be  so  prepared  as  to  last 
almost  any  desired  time.  It  may  in  fact  be  rendered  almost  unab- 
sorbable  by  excess  of  chromic  acid.  In  this  way  very  small  gut  may 
be  made  to  do  the  work  of  that  which  is  much  larger  ;  which  in  fine 
work  is  a  considerable  advantage  ;  and  the  time  which  will  be  re- 
quired for  its  absorption  may  be  accurately  regulated  by  that  during 
which  it  is  subjected  to  the  acid. 

All  of  these  different  materials  for  sutures  and  ligatures  are  put 
up  in  a  very  neat  form  by  George  Leavens,  Bible  Ilouse,  Xew  York, 
and  for  one  who  is  only  called  upon  to  operate  at  comparatively  long 
intervals  I  know  of  no  more  convenient  arrangement. 

Pieces  of  gut  about  three  yards  long  are  wound  on  glass  rods  and 
placed  in  a  glass  tube  containing  alcohol.     The  tube  is  hermetically 


Fig.  27. — Opened  at  Operation. 

sealed,  and  the  contents  sterilized  by  heat  {250°  F.).  Across  each 
tube  a  scratch  is  made  with  a  file  to  facilitate  breaking.  AVlien  a 
piece  of  any  material  is  needed  the  tube  is  first  lield  in  bichloride 


GENERAL  RULES  REGARDING  OPERATIONS. 


41 


Fig.  28.— Sterilizer  for  Hot  and  Cold  Water. 


42 


SUKGEllY    UF    THE    llECTL3r    AXD    PELVIS. 


solution  till  the  outside  is  sterile,  or  it  is  grasped  in  tlie  liands  cov- 
ered with  a  sterilized  towel,  and  by  a  combined  pulling  and  bending 
motion  the  tube  is  broken  where  it  is  scratched.  The  enclosed  rod,  ' 
with  the  suture,  is  dropped  into  the  glass  dish  containing  alcohol, 
which  is  on  the  table  for  this  purpose,  and  the 
gut  is  cut  as  needed. 

Sterilized  Water. — To  provide  both  hot  and 
cold  sterilized  water  hospital  operating-rooms  are 
usuall}^  fitted  with  a  special  steam  apparatus, 
such  as  is  shown  in  Fig.  28.  In  private  houses, 
water  that  has  been  boiled  and  is  still  nearly  at 
boiling  point,  can  easily  be  brought  from  the; 
kitchen  ;  and  cold  distilled  water  can  readily  be 
obtained  in  five  gallon  demijohns. 

Dressings. — For  sterilizing  towels,  dressings, 
operating  gowns,  suits,  etc.,  the  apparatus  shown 
in  Fig.  29  is  especially  adapted  in  hospitals.  In 
private  houses  a  small  sterilizer  such  as  is  shown 
in  Fig.  30  may  be  carried  to  the  operation,  or 
everj- thing  may  be  prepared  hy  the  operator  be- 
fore leaving  his  own  home,  and  carried  to  the 
house  in  sterilized  towels. 

The  sterilizer  shown  in  Fig.  30  is  one  arranged  by  Dr.  Meyer,  and 
answers  every  purpose.     There  are  several  others  in  the  market,  more 


Fig.  29. — Sterilizer  for 
Dressings. 


Fig.  30. — Portable  Sterilizer. 


or  less  perfect,  and  each  surgeon  will,  after  a  time,  adopt  some  rou- 
tine plan  and  style  of  apparatus  w^hich  will  best  meet  his  require- 
ments. 


GENERAL    RULES    REGARDING    OPERATIONS.  43 

Sponges  are  best  made  of  pads  or  balls  of  absorbent  gauze,  of  va- 
rious sizes,  for  vaginal,  rectal  or  abdominal  work.  The  pads  should 
be  about  half  an  inch  thick  and  range  in  size  from  two  inches  square 
up  to  eight  inches,  for  holding  back  the  intestines  in  coeliotomies. 
The  balls,  which  are  made  by  filling  a  small,  square  piece  of  gauze 
with  other  pieces  and  confining  the  whole  with  a  puckering  string, 
which  is  cut  short,  should  be  about  half  the  size  of  a  billiard-ball. 


Fig.  31. — Sponge-holder. 

These  are  chiefly  of  advantage  in  the  rectum  or  vagina,  and  should 
be  held  in  sponge-holders.  An  excellent  sponge  for  work  in  private 
can  be  made  of  simple  balls  of  absorbent  cotton,  which  has  been 
thoroughly  sterilized. 

The  gauze  pads  can  be  thoroughly  and  easily  washed,  and  re- 
sterilized,  by  boiling  after  each  operation,  and  kept  in  a  glass  jar  in 
a  solution  of  bichloride  1  to  2,500.  Either  of  the  forms  of  sponge- 
holders  shown  in  Figs.  31  and  32  will  answer  perfectly. 

The  fashion  of  the  hour  is  to  use  gauze  or  absorbent  cotton  exclu- 
sively for  dressings,  and  many  of  our  young  house-surgeons  are  un- 
familiar with  any  other  material.  Gauze  for  an  occasional  operation 
can  be  purchased  at  any  supply  store,  already  sterilized  and  packed 
in  glass  or  tin  boxes.  It  is  of  three  varieties  generally— the  plain 
sterilized,  the  same  impregnated  with  bichloride,  and  with  iodoform. 
For  general  surgery  a  gauze  which  has  been  medicated  with  balsam 
of  Peru  is  also  much  used.     Care  must  be  taken  not  to  use  bichloride 


Fig.  32.— Sponge-holder. 


or  iodoform  gauze  to  any  extent  in  large  wounds  to  prevent  toxic 
constitutional  effects. 

Dralnage-htbes .—T\\e^e  are  best  made  as  wanted  at  the  moment 
of  the  operation.  In  every  well-appointed  operating-room  a  jar  of 
gutta-percha  tissue  in  bichloride  solution  will  be  found.  When  a 
drain  is  wanted  roll  a  piece  of  plain  gauze  to  the  size  and  length 
desired,  cover  it  with  a  wrapper  of  this  tissue,  cut  off  the  ends  evenly, 
cut  fenestra  in  the  sides  of  the  gutta-percha  to  allow  of  free  endosmo- 
sis,  and  the  tube  is  complete.     It  is  much  better  than  glass,  and  very 


44 


SUEGERY   OF   THE   EECTUM   AND   PELVIS. 


Fig.  33.— Nozzle  for  Irrigator. 


Pig.  34. — Clover's  Crutch. 


Fig.  35. — Ovariotomy  Pad. 


GENERAL  RULES  REGARDING  OPERATIONS. 


45 


much  better  than  a  simple  roll  of  gauze  without  the  rubber  covering, 
which  in  abdominal  work  becomes  so  thoroughly  agglutinated  to  the 
living  tissues  by  means  of  plastic  exudation  as  to  be  practically  im- 
movable in  a  few  hours  without  violence  and  pain. 

Irrigation  in  a  private  house  is  usually  done  with  a  fountain 
syringe  suspended  near  the  table.  The  important  point  is  to  have 
the  stream  readily  under  control  and  to  have  the  nozzle  and  all  that 
end  of  the  tube  liable  to  be  touched  during  the  operation  sterile. 
The  best  nozzle  is  the  hard-rubber  one  shown  in  Fig.  83,  by  which  the 
stream  can  be  turned  on  or  off  in  a  moment.  This  and  a  yard  of  tub- 
ing can  easily  be  sterilized  with  the  other  instruments  and  attached 
to  a  fountain  syringe  at  the  house.  Two  other  essentials  for  all  rec- 
tal or  gyngecological  work  in  private  houses  are  the  Clover's  crutch 


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_A 

Fig.  36. — Kelly  Leg -holder. 


(Fig.  34),  or  some  modification  of  it,  and  the  Kelly  ovariotomy  pad 
(Fig.  35). 

The  Kelly  leg-holder  is  a  good  one,  and  avoids  the  disadvantage 
of  the  cross-bar,  which  is  often  in  the  way  during  the  operation 
(Fig.  36). 

F\nal  Preparations. — When  the  instrument- table  has  been  com- 
pletely covered  with  sterilized  towels  so  that  no  part  of  the  top  or 
edges  can  be  seen  ;  when  the  instruments  have  been  sterilized  and 
laid  in  the  dishes  upon  the  table  with  the  bottles  of  sutures  and 
ligatures  previously  uncorked  ;  when  sponges,  dressings,  and  irriga- 
tor are  ready,  the  patient  previously  etherized  may  be  placed  upon 
the  operating-table  and  the  parts  to  be  operated  ujDon  scrubbed  and 
cleaned. 


46  SURGERY    OF   THE   RECTUM    AND    PELVIS. 

For  working  within  the  rectum  the  anus  should  first  be  gently 
but  thoroughly  dilated  with  the  fingers.  A  Sims  speculum  (Fig.  17) 
should  then  be  introduced  and  the  rectum  thoroughly  'irrigated  with 
1  to  500  bichloride.  This  will  not  be  found  too  strong  if  it  is  allowed 
to  flow  out  as  fast  as  introduced.  Next,  the  mucous  membrane 
should  be  thoroughly  wiped  off  with  pledgets  of  iodoform  gauze,  and 
if  the  operation  permits  it,  a  plug  of  gauze  should  be  passed  into  the 
gut  above  the  field  of  operation  to  prevent  the  descent  of  mucus  or 
fecal  matter. 

Essentially  the  same  course  may  be  followed  in  vaginal  work,  ex- 
cept that  the  vagina  should  first  be  well  scrubbed  with  green  soap 
and  a  small  long-handled  brush. 

For  the  skin  and  parts  near  the  site  of  the  incision  I  am  usually 
content  with  a  thorough  scrubbing  first  with  green  soap  and  brush  ; 
with  shaving  the  skin  ;  and  with  final  thorough  washing  with  bi- 
chloride 1  to  500 ;  but,  if  all  previous  preparation  of  the  parts  has 
been  dispensed  with,  this  must  be  done  very  thoroughly  and  under 
the  personal  direction  of  the  operator. 

If  the  lithotomy  position  is  decided  upon,  the  feet  and  legs  should 
be  encased  in  loose  linen  bags  which  come  up  to  the  thighs  ;  the 
abdomen  and  edges  of  the  table  covered  with  sterilized  towels  pinned 
together  with  sterilized  safety-pins,  and  over  all  it  is  well  to  throw  a 
large  square  sterilized  sheet,  which  has  a  hole  cut  in  the  middle  to 
expose  the  site  of  operation  (Fig.  37).  A  similar  sheet  or  heavier  canvas 
cover  with  an  oval  opening  answers  well  for  abdominal  coeliotomies. 

From  what  has  been  said  it  will  be  seen  that  the  essentials  of  an- 
tisepsis, either  in  private  or  hospital  practice,  are  boiling  water,  water 
which  has  either  been  boiled  and  allowed  to  cool,  or  distilled ;  plenty 
of  towels ;  and  finally  an  apparatus  by  Avhicli  towels,  gowns,  and 
dressings  can  be  subjected  to  steam  for  half  an  hour,  and  instruments 
boiled  in  a  solution  of  washing  soda  for  ten  or  twenty  minutes.  The 
rest  is  a  matter  of  technique  depending  entirely  upon  the  operator, 
and  no  amount  of  previous  preparation  will  enable  a  man  whose 
methods  are  faulty  to  go  through  an  operation  antisepticly. 

The  Paquelin  cautery  is  an  instrument  so  frequently  used  in 
operations  about  the  rectum  that  a  word  or  two  about  its  care  and 
management  may  be  useful.  When  properly  handled  it  is  perfectly 
reliable  ;  under  other  circumstances  it  becomes  a  source  of  constant 
annoyance.  The  most  frequent  cause  of  failure  to  work  will  be  found 
to  be  the  forcing  of  the  vapor  of  benzine  into  the  tip  before  the  latter 


GENERAL  RULES  REGARDING  OPERATIONS. 


47 


'is  hot  enougli  to  ignite  it,  and  lience  tlie  coating  of  the  hollow  tip  with 
non-inflammable  deposit  which  renders  the  instrument  useless  until 
it  has  been  burned  out  over  a  Bunsen  burner.  Recetitl}^  many 
patterns  of  this  instrument  have  been  put  upon  the  market,  and 


Fig.  37. — Patient  Prepared  for  Operation. 

except  for  the  fact  that  the  tips  are  made  much  lighter  than  when 
protected  by  patents,  they  all  seem  to  work  about  equally  well,  and 
none  have  any  advantage  over  the  original  form,  in  which  the  benzine 
is  contained  in  a  glass  bottle  without  any  absorbent  material.  The  one 
shown  in  Fig.  38  has  the  advantage  of  dispensing  with  the  alcohol 
flame  or  gas-jet  necessary  to  start  the  instrument  in  the  old  patterns. 


48  SUEGERY   OF   THE   RECTUM   AIS^D   PELVIS. 

Hemorrhage  from  the  rectum  during  an  operation  must  be  met 
in  the  same  way  as  in  any  other  surgical  procedure — by  ligature, 
hot  water,  or  temporary  pressure.  Hemorrhage  coming  on  after  an 
operation  is  usually  best  met  in  one  of  two  ways.  Should  it  be  cu- 
taneous, or  come  from  just  within  the  external  sphincter,  a  compress 
and  T-bandage  properly  applied  will  always  give  sufficient  pressure 
to  control  it. 

The  compress  should  be  graduated  or  cone-shaped,  and  should  be 
of  ample  size  to  fill  the  fold  between  the  nates.  The  bandage  must 
be  strong  and  heavy  and  applied  with  force.  Care  must  be  taken  to 
protect  the  bony  points  of  the  pelvis  against  which  the  bandage  rests 
by  pads  of  cotton.     When  applied  in  this  way  a  direct  pressure  of 


Fig.  38.— Paquelin  Cautery. 

many  pounds  may  be  brought  to  bear  against  the  anus — a  pressure 
which  will  always  be  effective  against  a  superficial  hemorrhage. 

Where  the  bleeding  comes  from  the  rectal  pouch,  the  danger  is 
much  greater,  and  prompt  surgical  interference  may  be  necessary  to 
save  life.  This  form  of  bleeding  is  concealed,  and  only  shows  itself 
first  by  an  uncontrollable  desire  on  the  part  of  the  patient  to  go  to 
stool,  and  not  by  any  oozing  from  the  anus.  The  patient  sits  upon 
the  commode  and  passes  perhaps  a  pound  or  more  of  clotted  blood, 
feels  relieved,  and  returns  to  bed.  In  a  little  while  the  same  thing  is 
repeated  and  all  the  usual  constitutional  effects  of  hemorrhage  be- 
gin to  be  manifest.  I  have  known  a  patient  to  die  from  this  cause 
in  the  ward  of  a  large  hospital  because  a  stupid  nurse  did  not  ap- 
preciate the  necessity  for  calling  surgical  aid. 

Many  directions  have  been  given  for  dealing  with  this  condition, 


GENERAL    RULES    REGARDING    OPERATIONS.  49 

all  more  or  less  elaborate.  The  general  idea  which  still  possesses  the 
mind  of  the  amateur  is  that  some  sort  of  a  packing  should  be  put 
into  the  rectum  around  some  sort  of  a  tube — why,  I  cannot  imagine. 
The  bleeding  comes  from  the  rectal  pouch,  not  from  the  anus ;  and  it 
is  as  impossible  to  pack  the  rectal  pouch  by  inserting  a  tube  wound 
with  gauze  into  the  anus,  as  it  would  be  to  make  pressure  on  the  in- 
side of  a  bottle  by  crowding  in  a  tight  cork.  The  best  of  all  ways  is 
as  usual  the  simplest.  While  the  patient  gives  chloroform  to  himself, 
if  no  assistant  be  at  hand,  put  two  fingers  into  the  rectum  and  rap- 
idly clean  out  the  blood-clots.  Then  begin  and  pass  in  strips  of 
gauze,  each  two  yards  long  and  four  or  six  inches  wide.  Pass  the 
first  one  as  far  up  as  possible,  tie  the  second  to  it  and  pass  it  after  it ; 
and  so  with  a  third,  and  a  fourth.  When  the  cavity  begins  to  seem 
full,  crowd  the  whole  mass  as  far  up  as  possible,  and  pass  in  as  much 
more  as  the  pouch  will  contain,  leaving  the  free  end  of  the  last  pro- 
truding. Such  a  packing  may  be  allowed  to  remain  at  least  a  week 
and  will  cause  no  pain  or  uneasiness.  Flatus  will  escape  beside  it 
without  the  presence  of  any  tube,  and  it  will  soon  soften  so  as  to 
make  but  little  pressure  ;  but  for  the  first  twenty-four  hours  after  its 
introduction  concealed  hemorrhage  is  a  practical  impossibility. 

Retention  of  urine  is  of  frequent  occurrence  as  a  complication  of 
certain  affections  of  the  rectum,  and  after  operations  upon  these 
parts,  both  in  men  and  women,  and  it  should  always  be  in  the  mind 
of  the  surgeon.  It  is  not  generally  of  long  duration,  and  it  may  often 
be  overcome  by  a  bath  and  hot  applications  without  having  recourse 
to  the  catheter.  The  possibility  of  its  occurrence  should  never  be 
lost  sight  of.  Carelessness  in  this  matter  may  end  fatally  from  con- 
gestion of  the  kidneys. 


CHAPTER  lY. 

CONGENITAL    MALFORMATIONS. 

The  rectum  and  amis  are  developed  separately,  the  former  from 
the  internal  and  middle  layers  of  the  blastodermic  membrane,  the  lat- 
ter from  the  external.  The  lower  portion  of  the  primitive  intestine 
terminates  at  first  in  a  cloaca  common  to  it  and  the  nrachns.  About 
the  eighth  week  a  partition  is  formed  dividing  this  cavity  into  the 
uro-genital  and  the  rectum,  the  partition  being  the  perineum.  At 
the  same  time  a  depression  has  been  forming  in  the  skin  at  the  site  of 
the  anus  and  gradually  extending  upward  to  meet  the  blind  rectal 
pouch.     These  unite  about  the  end  of  the  fourth  week. 

The  malformations  of  the  rectum  and  anus  found  at  birth  are  due 
either  to  a  failure  on  the  part  of  nature  to  form  a  depression  in  the 
skin  sufiiciently  deep  to  meet  the  closed  rectum  above  ;  to  failure  of 
the  rectal  cul-de-sac  to  descend  sufficiently  to  meet  the  depression 
which  is  formed ;  or  to  an  arrest  of  development  of  the  tissues  be- 
tween the  rectum  and  genito-urinary  tract. 

These  congenital  malformations  have  been  classified  by  different 
writers  into  various  groups.  We  shall  adopt  in  the  following  pages 
that  of  Papendorf. 

1.  Narroioing  of  tlie  Anus  or  Rectum  without  Complete  Occlu- 
sion.— The  narrowing  in  these  cases  may  be  very  slight,  or  may  reach 
such  a  degree  as  hardly  to  admit  of  the  passage  of  meconium.  It  is 
generally  annular  in  form,  resembling  the  contraction  which  would 
be  caused  by  tying  a  tape  tightly  around  the  tube  ;  though  it  some- 
times involves  a  considerable  extent  of  bowel,  as  in  a  case  reported 
by  Cheever,  where  the  narrowed  portion  above  the  sigmoid  fiexure 
was  eighteen  inches  long  and  was  impervious  to  solids.  There  ma}''  be 
no  symptoms  caused  by  such  a  contraction,  and  the  child  may  grow 
to  adult  life  suffering  only  from  obstinate  constipation.  On  the  other 
hand,  when  the  stricture  is  tight  it  w^ill  give  rise  to  all  the  usual 
signs   of  such  a   condition  in   the  child — absence   of  free  passage 


CONGENITAL  MALFORMATIONS.  51 

of  meconium,  distention  of  the  abdomen,  and  vomiting.  Tlie  diag- 
nosis is  easily  made  by  a  digital  examination,  should  the  symptoms 
be  sufficiently  marked  to  lead  the  attention  of  the  surgeon  to  the 
rectum,  for  the  stricture  is  generally  near  the  anus. 

It  has  happened  to  me  in  the  course  of  practice  to  meet  several 
examples  of  this  form  of  disease,  and  one  of  the  most  notable  points 
in  connection  with  them  has  been  that  they  have  usually  first  been 
diagnosticated  in  middle  life,  their  congenital  nature  being  made 
plain  by  the  absence  of  any  disease  which  could  cause  them,  and 
more  especially  by  the  absence  of  any  associated  ulceration  or 
deposit  in  the  adjacent  parts  of  the  rectum. 

The  treatment  of  this  form  of  obstruction  consists  either  in  grad- 
ual dilatation  or  in  proctotomy.  My  own  experience  in  these  rare 
cases  tends  to  the  conclusion  that  gradual  and  systematic  dilatation 
will  accomplish  little,  and  that  nothing  short  of  a  free  division  or  a 
complete  excision  of  the  contracted  part  is  likely  to  be  of  much  per- 
manent benefit. 

2.  Closure  of  tlie  Anus  hy  a  Membranous  Diaphragm. — The 
membrane  in  these  cases  may  be  of  greater  or  less  firmness  and 
thickness,  and  may  be  composed  of  skin  or  of  mucous  membrane. 
It  is  sometimes  so  thin  as  to  bulge  out  with  meconium  when  the 
child  strains  or  coughs,  and  has  been  known  to  rupture  spontane- 
ously. It  is  also  occasionally  perforated,  like  the  hymen,  and 
allows  the  escape  of  considerable  quantities  of  meconium,  thus  tend- 
ing to  conceal  the  actual  condition  till  the  faeces  become  solid  and 
obstruction  takes  place. 

This  is  the  simplest  of  all  the  forms  of  congenital  malformation 
of  the  anus,  and,  unfortunately,  one  of  the  rarest.  It  is  easily 
diagnosticated  by  simple  inspection  of  the  parts  ;  and  the  treatment 
consists  in  making  a  crucial  incision  through  the  membrane.  The 
remains  of  the  membrane,  like  those  of  the  hymen,  which  it  strongly 
resembles,  will  shrink  up  so  as  not  to  cause  trouble  or  deformity. 

3.  Entire  Absence  of  the  Anus,  the  Rectum  ending  in  a  Blind 
Pouch  at  a  Point  more  or  less  distant  from  the  Perineum. — In  these 
cases  there  may  be  a  slight  depression  at  the  point  where  the  anus 
should  be  found  ;  or  there  may  be  no  trace  of  the  anal  orifice,  the 
raphe  of  the  perineum  extending  over  the  spot  and  back  to  the 
coccyx.  The  presence  of  a  slight  anal  depression  is  not  to  be  consid- 
ered as  an  indication  that  the  rectal  pouch  is  near  the  surface — 
in  fact,  some  of  Cripps'  figures  would  seem  to  indicate  exactly  the  re- 


52 


SURGERY    OF   THE   RECTUM    AND    PELVIS. 


verse.  The  external  spliincter  muscle  is  also  sometimes  present  and 
at  others  entirely  wanting.  The  pouch  of  the  rectum  in  these  cases 
may  hang  loose  in  the  pelvis  or  abdominal  cavity,  or  be  attached  to 
some  adjacent  part ;  and  the  space  between  it  and  the  perineum  may 
be  filled  up  with  cellular  tissue,  or,  in  other  cases,  a  distinct  fibrous 
cord  may  be  traced  from  the  rectal  pouch  to  the  skin,  as  is  shown  in 
the  plate  (Fig.  39). 

If  the  pouch  of  the  rectum  be  not  at  too  great  a  distance  from  the 
skin,  a  sense  of  fluctuation  may  be  felt  by  firm  pressure  with  one 


Fig.  39.— Rectum  ending  in  a  Blind  Pouch. 


finger  over  the  anus  and  the  other  hand  on  the  abdomen.  In  females, 
valuable  aid  in  diagnosis  may  be  obtained  by  the  introduction  of  a 
finger  into  the  vagina.  The  use  of  a  stethoscope  over  the  anus,  and 
of  percussion  on  the  abdomen,  has  been  recommended  to  detect  the 
rectal  pouch  filled  with  gas  ;  and  also  the  irritation  of  the  skin  over 
the  anus  to  provoke  efforts  at  defecation.  An  effort  should  always 
be  made,  w^iere  there  is  complete  absence  of  the  anus,  to  discover 
whether  the  rectum  may  not  have  some  outlet  through  the  bladder 
or  vagina,  which  will  place  the  case  in  one  of  the  classes  soon  to  be 
described. 

4.  T7ie  Rectum  may  he  the  same  as  in  the  Last  Variety,  and  the 
Anus  he  Normal  (Fig.  40).— The  septum  which  separates  the  rectal 
and  anal  pouches  in  this  case  is  generally  within  easy  reach  of  the 


CONGENITAL   MALFOllMATIONS. 


53 


anus,  and  may  be  so  thin  as  to  permit  a  sense  of  fluctuation.  In  most 
cases,  however,  the  septum  is  thicker,  and  is  composed  of  cellular  or 
fibrous  tissue,  lined  both  above  and  below  by  mucous  membrane.  It 
may  be  perforated,  like  the  hymen,  at  some  point,  and  allow  of  the 
slow  dribbling  of  meconium.  There  may  also  be  more  than  one 
septum.  Yoillemier  reports  one  case  in  which  the  rectum  was  divided 
in  this  way  into  four  distinct  compartments,  the  upper  one  contain- 
ing meconium  and  the  others  mucus.  There  is  generally  little  diffi- 
culty in  the  diagnosis  of  these  cases,  provided  only  a  digital 
examination  be  made  when  the  infant  begins  to  show  the  effects  of 


Fig.  40.  — Rectum  ending  in  Pouch  ;  Anus  Normal. 


the  obstruction  ;  but  the  danger  lies  in  the  fact  of  the  normal  anus, 
which  is  apt  to  allay  suspicion  as  to  the  true  nature  of  the  difficulty. 
In  the  diagnosis  of  the  third  and  fourth  varieties  it  is  of  the  great- 
est importance  to  determine  the  position  of  the  rectal  cul-de-sac. 
Unfortunately  this  is  seldom  possible  with  any  degree  of  accuracy. 
If  the  pelvis  be  of  normal  shape  and  the  genital  organs  in  the  natural 
position  ;  if  on  crying  or  straining  there  is  a  distinct  protrusion  in  the 
anal  region,  then  the  probability  that  the  pouch  is  within  easy  reach 
is  strong.  But  the  cases  in  which  any  protrusion  or  fluctuation  can 
be  detected,  even  by  tickling  the  perineum,  pressing  upon  the  abdo- 
men, or  exciting  the  child  to  sneeze  or  cough,  are  very  rare  ;  and  any 
attempt  to  cause  a  protrusion  by  the  use  of  purgatives  is  utterly 
unjustifiable. 


54 


SURGERY  OF  THE  EECTUM  AND  PELVIS. 


It  has  been  recommended  to  delay  operation  for  a  day  or  two,  if 
the  symptoms  are  not  very  urgent,  in  order  to  give  the  rectum  an  op- 
portunity to  become  more  distended  and  prominent.  Such  advice  is 
quite  erroneous,  as,  in  the  first  place,  the  meconium  becomes  less  by 
the  absorption  of  fluid,  and — what  is  more  important — while  we  are 
waiting  the  time  may  slip  away  when  alone  a  chance  of  success  exists. 

Nearness  of  the  tuberosities  is  often  a  sign  that  the  rectal  cul-de- 
sac  is  high  up.    Exploration  by  the  bladder  or  vagina  sometimes 


Fig.  41. — Rectum  ending  in  Glans  Penis. 

gives  useful  results  ;  for  if  the  vagina  or  bladder  fill  up  the  concavity 
of  the  sacrum,  it  is  proof  that  the  intestinal  ciCl-de-sac  is  high  up,  and 
colostomy  is  indicated  from  the  first. 

In  one  case  of  this  fourth  variety  which  came  under  my  notice 
the  child  had  reached  nearly  four  years  of  age  and  was  well  nour- 
ished, but  was  suffering  from  chronic  intestinal  obstruction.  The 
history  was  simply  of  constipation  ever  since  birth,  and  of  no  passage 
for  several  days  before  coming  to  the  hospital.  Examination  revealed 
what  seemed  to  be  a  thin  membranous  partition  at  about  one  inch 
and  a  half  from  the  anus.  There  was  marked  bulging  of  the  rectal 
pouch  against  the  finger  when  the  child  cried,  and  at  one  point  a 
small  depression  in  the  septum  could  be  made  out  with  the  end  of 
the  finger.  Although  the  finger  could  not  be  made  to  enter  this 
orifice,  pressure  against  it  seemed  to  dilate  it  to  an  extent  sufficient 
to  cause  the  escape  of  a  stream  of  fiuid  faeces  several  inches  from  the 
anus  when  the  finger  was  removed.  Operation  was  refused  and  the 
child  passed  out  of  sight. 


CONGENITAL  MALFORMATIONS. 


55 


5.  The  Anns  may  he  Absent,  and  the  Rectum  may  open  hy  an 
Abnormal  Anus  at  any  Point  in  the  Perineal  or  Sacral  Region.— 
When  tlie  rectum  terminates  in  the  glans  penis,  the  labia,  or  at  some 
abnormal  point  in  the  perineum,  the  lower  portion  of  it  is  usually  of 
a  fistulous  character,  as  shown  in  the  plate  (Fig.  41),  but  lined  by 
true  mucous  membrane  ;  and  the  anus,  whether  in  the  perineum  or 
at  the  base  of  the  sacrum  or  tip  of  the  coccyx,  is  always  narrow  and 
insufficient  for  its  purpose.     A  modification  of  this  class  of  abnor- 


FiG.  42. — Rectum  ending  in  Bladder. 

malities  is  found  in  those  cases  where  the  rectum  terminates  in  two 
openings  at  a  greater  or  less  distance  from  each  other. 

6.  The  Anus  may  be  Absent  and  the  Rectum  may  end  in  the 
Bladder,  Urethra,  or  Vagina  (Fig.  42). — Forty  per  cent,  of  all  cases 
are  included  in  this  class,  and  that  in  which  the  rectum  opens  into 
the  vagina  is  the  most  common.  In  females  the  opening  is  seldom, 
if  ever,  into  the  bladder,  but  sometimes  it  is  into  the  urethra.  In 
males  it  is  more  often  into  the  bladder  than  into  the  urethra,  and  in 
such  cases  the  rectum  may  terminate  either  by  a  narrow  duct  run- 
ning obliquely  through  the  bladder  and  opening  in  the  bas-fond  be- 
tween the  orifices  of  the  ureters,  or  by  a  free  opening.  The  symp- 
toms of  this  condition  will  of  course  vary  greatly  according  to  the 
location  of  the  abnormal  opening.  When  the  communication  is  be- 
tween the  rectum  and  bladder,  the  fact  will  be  shown  by  the  mixture 
of  the  meconium  with  the  urine,  rendering  the  latter  thick  and  green- 
ish in  color.     The  amount  of  meconium  present  will  also  indicate 


56  SUEGERY    OF   THE    RECTUM    AND    PELVIS. 

whether  the  opening  is  large  or  small.  This  condition  is  generally 
fatal,  from  the  development  of  cystitis  and  from  intestinal  obstruc- 
tion, unless  the  condition  be  relieved  by  the  appropriate  surgical  in- 
terference. 

When  the  communication  is  urethral  in  the  male,  the  meconium 
will  often  escape  independently  of  the  act  of  urination  ;  and  although 
the  first  flow  of  urine  may  be  mixed  with  meconium ,  the  remainder 
will  be  clear.  '  The  prognosis  is  not  as  bad  in  these  cases  as  in  the 
vesical  variety,  several  being  recorded  in  which  life  has  been  pre- 
served for  a  number  of  years.  Gross  relates  one  case  in  a  man  aged 
thirty,  and  Bodenhamer  cites  several  others  in  which  children  have 
lived  three  or  four  years. 

In  the  female  the  prognosis  is  more  favorable  than  in  the  male, 
from  the  greater  facility  with  which  the  meconium  escapes. 

Where  the  abnormal  opening  is  between  the  vagina  and  rectum, 
and  is  of  considerable  size,  as  it  generally  is,  the  prognosis  is  not 
necessarily  grave.  Women  have  been  known  to  live  to  a  good  old 
age,  even  to  reach  one  hundred  years  in  the  case  of  Morgagni,  with 
this  malformation,  and  to  perform  all  the  duties  of  wives  and  moth- 
ers, without  even  being  conscious  of  anything  abnormal  (Fournier, 
Ricord). 

In  absence  of  the  rectum,  if  there  exists  a  vesical  communication 
the  intestine  is  high  up  and  colostomy  is  indicated  ;  if,  on  the  other 
hand,  there  exists  a  communication  with  the  urethra,  the  intestine 
is  low  down  and  should  be  searched  for  in  the  perineum.  When 
there  is  a  communication  between  intestine  and  bladder,  the  possi- 
bility of  a  malformation  of  the  ureters  and  of  the  genital  tract  must 
be  borne  in  mind. 

7.  The  Rectum  and  Anus  are  Normal,  hut  the  Ureters,  Uterus, 
or  Vagina  empty  into  the  Rectal  Cavity  and  discharge  their  Con- 
tents through  2'^.— This  species  of  malformation  is  rare,  and  is  usually 
attended  by  other  signs  of  imperfect  development.  It  is  not  incom- 
patible with  life  or  with  conception. 

8.  Total  Absence  of  the  Rectum.— This  variety  differs  only  from 
the  third  in  the  amount  of  the  rectum  which  may  be  absent.  It  may 
or  may  not  be  attended  by  an  absence  of  the  anus,  but  is  usually 
only  one  of  the  signs  of  arrested  development.  The  blind  pouch  of 
the  rectum  may  hang  loose  in  the  abdomen  or  pelvis  ;  may  be  at- 
tached at  the  base  of  the  sacrum  or  to  some  of  the  adjacent  parts ; 
or  may  be  continued  down  as  a  fibrous  cord  to  the  site  of  the  anus. 


CONGENITAL    MALFORMATIOjSTS. 


57 


9.  Absence  of  tlie  Large  Intestine. — This  is  also  attended  by  an 
absence  of  tlie  normal  anus,  the  place  of  which  is  supplied  by  an  ab- 
normal opening  in  the  umbilicus,  or  at  some  remote  part  of  the 
body,  as,  for  example,  the  side  of  the  chest,  or  the  face.  With  this 
abnormal  opening  the  small  intestine,  or  what  remains  of  the  colon, 
communicates. 

Thus  far  only  arrests  or  excesses  of  development  have  been  men- 
tioned. The  rectum  and  anus  are,  however,  liable  to  certain  dis- 
eases during  fetal  life  which  may  result  in  narrowing  or  completely 
obliterating  their  calibre.     Among  these  are  enteritis  and  proctitis. 

The  longest  possible  period  of  life  in  a  child  with  absolutely  im- 
pervious rectum  has  not  yet  been  determined.  In  a  case  reported  by 
Cripps  the  diagnosis  was  made  on  the  third  day,  but  treatment  was 
not  permitted,  and  the  child  was  brought  back  thirty  days  later,  still 
to  all  appearances  quite  well,  but  with  distended  abdomen  and  fecal 
vomiting.  How  much  longer  she  might  have  lived  had  not  operative 
measures  been  immediately  fatal,  cannot  be  judged.  Another  case 
has  been  recorded  in  which  the  trocar  was  used  on  the  twenty- 
seventh  day,  giving  temporary  relief,  and  there  are  accounts  of  even 
longer  periods. 

The  prognosis  depends  in  great  measure  upon  the  form  of  the 
anomaly.  In  the  varieties  first  described,  in  which  the  condition  is 
easily  remedied,  it  is  exceedingly  good.  It  is  also  good  in  cases 
where  the  rectum  communicates  with  the  vagina.  In  all  the  others 
it  is  bad,  and  too  much  must  not  be  expected  from  the  line  of  treat- 
ment to  be  described.  An  opening  may  be  made  either  in  perineum 
or  groin,  life  may  be  prolonged,  immediate  relief  may  be  given,  and 
occasionally  adult  age  may  be  reached  in  comfort ;  but  the  opera- 
tions themselves  are  severe  and  sometimes  fatal,  and  when  imme- 
diately successful  the  children  do  not  seem  to  thrive.  Cripps  has 
tabulated  one  hundred  of  these  cases  of  all  varieties,  and  his  table  is 
very  instructive.     It  is  as  follows 


16  cases  colon  opened  in  groin, 
"         "  loin. 


3 

17 

" 

8 

39 

14 

3 

00 

cases 

puncture, 

coccyx  resected, 

perineal  dissection  or  incision, 

communication  with  vagina, 

niiscellaneous, 


11  died. 

2  " 
14  " 

5  " 

14  " 

1  " 

3  " 


50  died. 


58  SURGERY    OF   THE   RKCTU3I   AND   PELVIS. 

Of  tlie  fifty  deaths,  fourteen  were  from  peritonitis,  ten  from  fail- 
ure to  give  relief,  and  nineteen  more  probably  from  the  same  causes, 
though  the  cause  is  not  recorded.  In  spite  of  this  unfavorable  show- 
ing, the  surgeon  must  do  what  he  can.  There  is  always  the  hope 
that  the  rectum  may  be  reached  from  the  perineum  ;  and  even  if 
this  fail,  a  child  with  an  artificial  anus  in  the  groin  may  be  very 
comfortable. 

The  treatment  of  the  class  of  congenital  contractions  of  the  anus 
and  rectum,  and  of  the  class  of  membranous  septa,  has  already  been 
referred  to  and  is  exceedingly  simple  and  generally  attended  by  good 
lesults.  The  treatment  of  the  remaining  varieties,  except  the  eighth 
and  ninth,  which  do  not  admit  of  surgical  interference,  may  be 
guided  by  the  following  general  propositions  : 

1.  A?i  Ox>eration  sliould  alioays  he  performed  loithout  Delay. — 
There  is  nothing  to  be  gained  by  waiting  for  the  rectal  pouch  to  be- 
come distended  with  meconium,  and  there  is  much  to  be  lost.  If  the 
obstruction  be  complete,  death  is  a  necessary  result ;  being  produced, 
generally  within  the  first  week,  by  peritonitis,  rupture  of  the  over- 
distended  bowel,  or  by  a  gradual  wasting  without  acute  symptoms. 
Even  in  cases  where  a  certain  amount  of  m.econium  makes  its  escape 
by  a  narrow  orifice,  and  delay  is  not,  therefore,  as  necessarily^  danger- 
ous as  in  cases  of  complete  obstruction,  nothing  is  to  be  gained  by 
delay,  and  an  immediate  operation  may  avoid  a  paralysis  of  the 
bowel  from  overdistention. 

The  only  exceptions  to  the  rule  of  early  operation  are  those  in 
which  there  is  a  free  communication  between  rectum  and  vagina.  The 
patient  is  in  no  danger,  and  the  operation  can  be  performed  better  as 
the  parts  become  better  developed.  And,  again,  in  cases  of  com- 
munication between  the  rectum  and  urinary  tract  the  demand  for 
operation  is  not  immediate,  and  time  may  be  taken  to  ^vatch  the  case 
and  determine  whether  the  opening  be  vesical  or  urethral.  In  fact, 
several  weeks  often  elapse  before  such  a  child  is  seen  at  all  by  the 
surgeon. 

2.  //  there  he  any  Chance  of  establishing  an  Opening  at  the 
Normal  Site  of  the  Anns,  the  Surgeon  should  at  first  direct  his  At- 
tention to  this  Procedure. — And  since  in  most  cases  it  is  impossible 
to  tell  that  the  rectal  pouch  may  not  be  within  easy  reach  from  the 
perineum,  it  is  generally  good  surgery  to  make  a  tentative  incision  at 
this  point. 

Before  attempting  any  operation  on  a  child's  pelvis,  the  surgeon 


CONGENITAL   MALFORMATIONS.  59 

should  remember  the  exceeding  smallness  of  the  space  in  which  he  is 
obliged  to  work,  even  in  its  natural  state  ;  and  also  that  the  normal 
measurements  may  be  decreased  in  any  case  of  congenital  malforma- 
tion. These  normal  measurements,  according  to  Bodenhamer,  who 
made  them  on  two  new-born,  well-developed  male  infants  at  full  term, 
are  as  follows : 

First  case  :  From  one  tuberosity  of  the  ischium  to  the  other,  one 
inch  and  one  line.  From  the  os  coccygis  to  the  symphysis  pubis, 
one  inch  and  three  lines.  From  the  os  coccygis  to  the  promontory  of 
the  sacrum,  one  inch  and  two  lines. 

Second  case :  From  one  tuberosity  of  the  ischium  to  the  other,  one 
inch.  From  the  os  coccygis  to  the  symphysis  pubis,  one  inch  and 
one  line  and  a  half.  From  the  os  coccygis  to  the  promontory  of  the 
sacrum,  one  inch  and  one  line. 

The  means  at  the  disposal  of  the  operator  for  reaching  the  rectal 
pouch  through  the  perineum  and  establishing  a  new  outlet  consist  in 
puncture,  incision  (proctotomy),  and  in  the  formation  of  a  new  anus 
by  a  plastic  operation  (proctoplasty).  The  operation  by  puncture 
consists  in  plunging  a  trocar  through  the  perineum  in  the  supposed 
direction  of  the  rectum,  for  the  purpose  of  establishing  an  outlet. 
It  may  be  done  without  a  preliminary  incision,  or  after  a  careful  dis- 
section which  has  failed  to  reach  the  desired  point. 

3.  The  Use  of  a  Trocar  as  an  Aid  in  finding  the  Rectal  Pouch, 
before  or  after  Incisions  through  the  Perineum,  is  not  sanctioned  by 
Modern  Surgical  Authority. — In  the  faint  hope  of  finding  one  thing 
which  he  does  not  know  to  be  there,  the  surgeon  takes  the  risk  of 
wounding  two  things  which  are  always  there — the  peritoneum  and 
the  bladder — and  a  wound  of  either  of  these  may  be  fatal. 

Another  and  almost  equally  strong  objection  to  this  procedure  is 
the  fact  that  it  is  utterly  useless  even  when  successful.  It  allows  of 
an  immediate  escape  of  the  contents  of  the  bowel,  but  that  is  all. 
No  such  opening  can  be  made  to  do  duty  permanently  as  an  anus  by 
any  amount  of  care  or  subsequent  dilatation. 

The  peculiar  mortality  attending  the  use  of  the  trocar  is  shown 
by  the  fact  of  fourteen  deaths  in  seventeen  punctures,  mostly  from 
peritonitis.  The  conformation  is  often  such  that  it  is  impossible  to 
avoid  peritoneum  even  when  a  successful  puncture  is  made  and  me- 
coneum  is  evacuated  ;  for  the  peritoneal  sac  may  extend  down  on 
the  lower  end  of  the  cul-de-sac  so  as  nearly  to  cover  it,  then  be  re- 
flected on  to  the  bladder  in  the  usual  way.     In  such  a  case,  if  a  punct- 


60  SURGEKY    OF   THE   EECTUM   AND   PELVIS. 

ure  be  made  from  below,  the  trocar  will  enter  and  leave  the  peritoneal 
cavity  before  reaching  the  rectal  pouch,  and  when  this  is  reached  it 
is  simply  allowed  to  drain  into  the  peritoneal  cavity  after  removal  of 
the  instrument. 

4.  Tlie  Results  of  Attempts  to  estctblish  an  Outlet  f 07^  an  Imperfor- 
ate Rectum  hy  means  of  Incisions  alone  through  the  Perineum  are  not 
favorable  as  regards  the  production  of  a  Useful  Anus. — The  opera- 
tion consists  in  cutting  through  the  perineal  tissues,  stroke  by  stroke, 
until  the  rectal  pouch  is  reached  and  opened.  The  incision  should 
be  longitudinal  and  should  reach  from  the  scrotum  to  the  tip  of  the 
coccyx.  Should  the  fibres  of  the  external  sphincter  be  encountered 
beneath  the  skin,  they  may  be  carefully  separated  as  near  the  median 
line  as  possible  and  drawn  to  each  side.  The  direction  of  the  dissec- 
tion, which  it  is  needless  to  say  should  be  made  with  the  utmost  care, 
should  be  backward  toward  the  concavity  of  the  sacrum  in  the  line 
which  the  rectum  normally  follows.  Additional  safety  may  be  secured 
by  the  introduction  of  a  sound  into  the  male  bladder  or  the  female 
vagina.  The  finger  is  to  be  frequently  used  as  a  director  in  exploring 
for  the  rectal  pouch,  while  the  hand  of  an  assistant  makes  pressure 
on  the  abdomen.  In  this  way  the  dissection  may  be  carried  to  the 
depth  of  an  inch  or  possibly  an  inch  and  a  half,  but  at  this  point,  if 
unsuccessful,  it  should  be  abandoned  for  fear  of  wounding  the  peri- 
toneum. 

This  operation,  though  it  may  be  successful  in  allowing  the  es- 
cape of  meconium  and  in  prolonging  life,  does  not,  in  most  cases, 
result  in  a  useful  anus  for  any  great  number  of  years.  This  is  the 
experience  of  the  greater  number  of  writers  upon  this  subject.  Van 
Buren  says  :  "I  have  in  several  instances  succeeded,  by  careful  dis- 
section, in  reaching  a  fluctuating  point  of  a  blind  rectal  pouch,  and 
in  establishing  a  free  outlet  for  the  meconium,  but  in  no  case  has  it 
proved  permanently  useful.  It  has  always  been  necessary  to  employ 
bougies  or  tents  more  or  less  constantly  to  keep  the  new  canal  from 
contracting,  and  the  care,  and  pain,  and  trouble  of  fighting  against 
the  closing  stricture,  and  the  persistent  tendency  to  obstruction  and 
fecal  accumulation,  have  invariably  led  to  early  death.  At  present 
I  know  of  no  such  case  treated  in  this  way  in  which  a  permanently 
satisfactory  result  has  been  attained."  Amussat,  Sir  Benjamin 
Brodie,  Yelpeau,  Benjamin  Bell,  and  many  others,  have  borne  testi- 
mony to  the  same  effect.  On  the  other  hand,  cases  are  occasionally 
seen  where  the  result  is  more  favorable,  but  they  constitute  a  small 


CONGENITAL   MALB^ORMATIOTSTS.  61 

minority  of  the  whole.  What  the  operation  really  accomplishes  is 
the  formation  of  a  fecal  fistula,  with  all  the  discomforts  attendant 
upon  such  a  condition. 

Proctoiplasty. — This  operation  is  the  same  as  the  last,  with  the 
addition  of  two  important  features.  In  the  first  place,  the  rectum  is 
drawn  down  and  stitched  to  the  skin  ;  and,  second,  to  facilitate  this, 
when  necessar}^,  either  the  new  anus  is  made  just  at  the  tip  of  the 
coccyx,  or  that  bone  is  exsected  and  the  anus  made  in  the  place  it 
occupied.  Where  much  of  the  lower  end  of  the  rectum  is  deficient, 
it  may  not  be  possible  to  draw  the  cul-de-sac  down  to  the  skin  with- 
out more  traction  and  dissection  than  it  is  safe  to  employ.  In  such 
cases  the  excision  of  the  coccj^x,  as  originally  recommended  and 
practised  by  Amussat,  and  more  recently  by  Verneuil,  besides  add- 
ing to  the  chances  of  finding  the  rectal  pouch,  diminishes  the  dis- 
tance over  which  the  rectum  must  be  stretched.  Unfortunately,  in 
the  cases  where  the  operation  is  most  needed — those  in  which  the 
rectal  pouch  is  farthest  from  the  skin — the  operation  is  not  alwaj^s 
practicable ;  and  in  other  cases  the  adhesions  of  the  rectum  to  the 
bladder  or  vagina  may  be  an  insuperable  obstacle. 

The  treatment  of  the  class  of  cases  in  which  the  rectum  opens 
into  the  vagina  offers  a  fair  chance  of  success.  If  the  opening  be 
sufficiently  large  to  permit  of  free  evacuation,  there  need  be  no 
hurr}^  to  operate  before  the  age  of  puberty.  At  this  time  the  con- 
formation of  the  parts  will  have  changed,  there  will  be  more  room  in 
which  to  work,  and  a  better  result  may  be  obtained.  Also  there 
sometimes  develops  such  an  amount  of  sphincteric  power  in  the 
vagina,  and  so  little  inconvenience  is  caused  by  the  condition,  that 
the  surgeon  should  seriously  consider  the  propriety  of  any  interfer- 
ence whatever.  Cases  are  on  record  in  which  this  malformation  has 
existed  in  wives  and  mothers  without  their  ever  having  suspected 
that  they  were  different  from  other  women.  On  the  other  hand,  if 
the  opening  be  merely  fistulous  in  character  and  only  large  enough 
to  permit  of  dribbling  of  meconium,  the  condition  will  grow  more 
serious  as  life  advances  ;  and  as  the  character  of  the  fseces  changes 
from  fluid  to  solid,  more  or  less  obstruction  begins  to  be  manifest, 
the  colon  becomes  distended  with  solid  matter,  and  the  condition 
will  end  fatally  unless  relieved. 

The  treatment  of  these  cases  is  comparatively  easy,  because  a 
bent  probe  passed  through  the  vaginal  opening  and  turned  toward 
the  perineum  marks  the  end  of  the  rectum  and  can  be  cut  down 


62 


SURGERY    OF   THE   llECTUM   AND   PELVIS. 


upon  through  the  skin.  After  this  has  been  done  the  rectum  should 
be  carefully  dissected  from  the  vagina  and  drawn  down  to  the  sur- 
face, if  possible.  This  is  known  as  Rizzoli's  operation,  and  is  per- 
formed as  follows  (Fig.  43)  : 

The  instruments  necessary  are  a  knife,  a  uterine  sound,  small 
toothed  retractors  (Fig.  44),  blunt-pointed  scissors,  medium  and  tine 


B 


Fig.  43. — Rizzoli's  Operation. 

A  shows  the  relative  position  of  the  parts  and  the  line  of  incision  (dotted). 
B  shows  the  parts  separated  and  the  anus  dissected  out. 
C  the  operation  completed. 

full-curved  Hagedorn  needles,  needle-holder,  artery  forceps,  and  fine 
catgut. 

With  the  patient  in  the  lithotomy  position,  and  the  feet  either  in 
the  stirups  or  the  legs  held  up  by  a  Clover's  crutch,  the  vaginal  anus, 
lower  end  of  the  rectum,  vagina,  and  perineum  should  first  be  ren- 


FlG.  44.— Toothed  Retractor. 


dered  thoroughly  aseptic.  The  best  way  to  accomplish  this  is  first 
to  wipe  out  the  anus  and  rectum  carefully  with  pledgets  of  iodoform 
gauze  held  in  dressing  forceps.  Next  wash  out  the  rectum  thor- 
oughly with  1  to  500  bichloride  solution,  and  plug  it  lightly,  so  as 


CONGENITAL    M ALP^ORMATIONS.  63 

not  to  distend  it,  witli  a  pledget  of  iodoform  gauze.  The  vagina  and 
perineum  should  next  be  scrubbed  with  green  soap  and  nail-brush, 
washed  with  bichloride  solution  1  to  1,000,  and  finally  with  ether. 

The  sharply  curved  uterine  sound  is  passed  into  the  rectum 
through  the  vaginal  orifice.  An  incision  is  made  in  the  median  line 
reaching  from  the  margin  of  the  anal  orifice  in  the  vagina  to  the  tip 
of  the  coccyx,  and  carried  deeply  enough  to  reach  the  surface  of  the 
rectum,  but  not  deeply  enough  to  open  it.  The  dissection  of  the 
rectum  requires  caution  ;  and  when  it  has  been  exposed  as  far  as 
possible  by  this  median  incision,  the  knife  is  to  be  carried  round  the 
vaginal  anus,  and  the  remaining  part  of  the  rectum  separated  from 
its  connections  until  the  anus  can  be  placed  without  much  traction 
in  the  posterior  angle  of  the  wound  as  near  as  possible  to  the  coccyx. 
The  separation  of  the  rectum  anteiiorly  should  be  freely  done,  and 
iifter  the  separation  of  the  anus  it  is  not  difficult.  The  margin  of  the 
anus  is  next  stitched  to  the  posterior  angle  of  the  wound,  next  the 
sides  of  the  vagina  are  united,  and  lastly  the  perineum.  This  order 
of  procedure  is  of  great  importance  when  working  in  so  small  a 
space.  Usually  the  faeces  pass  readily  and  no  dilatation  of  the  ori- 
fice is  required ;  but  should  this  be  thought  too  small,  it  may  be 
enlarged  by  a  posterior  median  incision.  It  is  essential  that  the 
anus  should  be  fixed  as  far  back  as  possible,  as  the  tendency  of  cica- 
trization is  to  draw  it  forward,  and  after  the  effects  of  the  operation 
have  passed  it  will  be  found  nearer  the  vagina  than  expected.  In 
stitching  the  anus  to  the  perineum  the  needle  should  never  enter  the 
calibre  of  the  bowel,  otherwise  asepsis  is  at  an  end.  The  success  of 
the  operation  will  depend  in  great  measure  upon  avoiding  suppura- 
tion, and  to  do  this  in  any  operation  involving  the  rectum  requires 
the  most  elaborate  precautions. 

Pack  the  vagina  lightly  with  iodoform  gauze,  cover  the  23erineum 
with  a  separate  piece  of  the  same,  and  apply  a  T-bandage.  The 
water  should  be  drawn  for  the  first  three  days,  and  the  perineal  pad 
changed  at  least  twice  a  day.  The  bowels  may  be  moved  at  the  end 
of  the  second  day  with  salines  and  an  enema. 

In  case  of  Failure  to  establisli  a  New  Anus  in  the  Anal  Region, 
Colostomy  should  at  once  he  performed. — The  teachings  of  different 
authorities  will  vary  as  to  the  propriety  of  first  performing  the  per- 
ineal operation  before  resorting  to  colostomy,  according  to  the  views 
of  each  one  upon  the  question  of  the  desirability  of  colostomy. 
Some  follow  the  rule  I  have  laid  down,  that  it  is  always  better  to  at- 


64  SURGERY    OF    THE    RECTUM   AND    PELVIS. 

tempt  the  perineal  operation  where  there  is  a  chance  of  its  succeed- 
ing ;  others  limit  the  latter  operation  to  cases  where  the  rectal  pouch 
is  known  to  be  near  the  skin,  and  in  all  others  turn  their  efforts  at 
once  toward  the  colon.  The  abdominal  operation  is  obviously  the 
only  one  where  the  rectum  ends  high  up  in  the  pelvis,  and  it  is 
generally  to  be  preferred  in  that  class  of  cases  where  it  opens  into  the 
bladder  or  urethra.  After  the  performance  of  colostomy,  when  the 
child  has  developed,  it  may  be  possible  to  do  a  successful  perineal 
operation  and  subsequently  close  the  opening  in  the  groin,  but  my 
one  single  attempt  to  do  this  ended  fatally  from  the  perineal  opera- 
tion. 

Rectal  Dwerticula. — In  connection  with  this  subject  of  congenital 
malformations  it  may  be  of  interest  to  know  that  a  few  cases  of  true 
diverticulum  of  all  the  coats  of  the  rectum,  similar  to  Meckel's 
diverticulum  from  the  ileum,  have  been  observed.  Ball  gives  one  in 
full  from  Hulke  ;  and  Maas,  of  Wiirzburg,  has  recently  reported  the 
following :  The  patient  was  a  boy,  aged  fourteen.  Shortly  after 
birth  the  abdomen  began  to  swell,  and  increased  in  size  as  years 
passed  by,  without  affecting  the  general  health,  till  the  age  of  thir- 
teen. At  this  time  the  swelling  became  much  larger  and  caused 
dyspnoea  and  palpitation.  Congenital  hydronephrosis  on  the  left 
side,  or  cystic  degeneration,  was  diagnosticated.  An  exploratory  in- 
cision was  made,  but  the  idea  of  an  operation  was  abandoned  and 
the  boy  died  suddenly.  The  tumor  proved  to  be  an  immense  diver- 
ticulum from  the  upper  part  of  the  rectum,  filled  with  fourteen  litres 
of  thin  faeces  and  containing  gas.  The  opening  of  comiuunication 
was  at  the  posterior  and  inferior  aspect  of  the  pouch.  The  rectum 
was  strongly  compressed  by  the  tumor. 


CHAPTER  Y. 

PROCTITIS    AND    PERIPROCTITIS. 

Inflammation  of  the  rectum  may  be  catarrhal,  dysenteric,  diph- 
theritic, or  gonorrhoeal. 

Catarrhal  proctitis  may  be  acute  or  chronic.  The  acute  form  is 
often  due  to  irritation,  perhaps  more  often  from  the  presence  of 
hardened  masses  of  faeces  in  the  rectal  pouch  than  from  any  other 
cause.  Ball  thinks  in  some  cases  this  may  be  due  to  chemical  action 
the  result  of  putrefactive  changes.  Of  this  I  have  no  proof,  but  the 
direct  mechanical  irritation  and  subsequent  ulceration  caused  in  this 
way  I  have  become  familiar  with  from  clinical  observation. 

In  children  the  presence  of  pinworms  may  cause  sufficient  irrita- 
tion to  produce  the  same  condition.  Other  causes  are  the  abuse  of 
drastic  purgatives  ;  the  prolonged  sitting  on  a  cold  or  wet  seat ;  and 
the  existence  of  some  other  disease  in  or  near  the  rectum  acting  as 
an  irritant,  such  as  a  neoplasm,  an  intussusception,  or  an  abscess 
around  the  rectum. 

Traumatic  proctitis  may  arise  from  a  multitude  of  causes.  For- 
eign bodies  which  have  passed  along  the  rest  of  the  canal  may  be- 
come lodged  in  the  rectum,  or  may  be  introduced  into  the  anus  and 
cause  direct  injury  to  the  rectum.  It  uirj  be  due  to  the  frequent  and 
improper  use  of  the  syringe  either  by  the  patient  or  a  heavy-handed 
nurse. 

By  far  the  worst  cases  of  chronic  catarrhal  inflammation  of  the 
rectum  I  have  ever  seen  were  due  to  small,  benign  polypoid  growths 
situated  high  up  in  the  rectum.  In  some  the  disease  had  existed  at 
least  ten  years  and  had  caused  the  usual  amount  of  irritation.  The 
patients  had  all  this  time  been  treated  for  ulceration  of  the  rectum  ; 
acid  had  been  frequently  applied,  the  strongest  astringents  had  been 
used,  the  "ulcer"  had  been  cut  and  scraped  ;  and  when  the  poly- 
pus was  finally  removed  the  mucous  membrane,  from  anus  to  sig- 
moid flexure,  was  soft,    thickened,  boggy,   granular,  and  bleeding 


QQ  SURGERY    OF   THE   RECTUM    AND    PELVIS. 

freely.  With  all  this  there  was  no  actual  ulceration  and  no  loss  of 
substance,  the  most  marked  sj^mptom  being  the  profuse  hemorrhage 
and  mucous  discharge. 

In  almost  all  cases  of  prolapsus  of  any  duration  there  will  be 
found  a  certain  amount  of  acute  or  chronic  catarrhal  proctitis  com- 
plicating the  original  trouble  and  disappearing  spontaneously  with 
its  removal  ;  and  the  same  is  true  of  many  cases  of  internal  hemor- 
rhoids. The  mucous  membrane  covering  the  tumors  at  first  becomes 
inflamed,  generally  from  direct  injury,  and  the  inflammation  thus 
commenced  is  continued  up  the  rectum  till  the  symptoms  of  proctitis 
or  ulceration  are  superadded  to  those  of  the  original  trouble. 

A  large  class  of  cases  of  catarrhal  proctitis  is  found  among  women 
with  uterine  misplacements.  Any  disease  of  the  uterus  which  causes 
undue  pressure  upon  a  certain  spot  in  the  rectal  wall  may  set  up  an 
inflammation  of  the  mucous  membrane  at  that  point,  the  symptoms 
of  which  may  mask  the  primary  disease.  Many  cases  of  women  suf- 
fering from  rectal  symptoms,  with  pains  in  the  back,  loins,  and 
thighs,  and  the  passage  of  bloody  and  mucous  stools,  will  be  found 
to  come  under  this  category. 

Another  cause  of  catarrhal  proctitis,  according  to  Esmarch  and 
Bushe,  is  gout,  alternating  with  the  manifestations  of  the  disease  at 
its  usual  localities. 

Dysenteric  proctitis  is  not  uncommon  in  the  southern  portions  of 
the  United  States,  and  is  by  no  means  unknown  in  certain  regions  of 
the  North,  especially  in  New  Jersey.  The  acute  cases  are  much  more 
apt  to  come  under  the  observation  of  the  physician  than  the  sur- 
geon, but  the  chronic  ulceration  and  strictures  are  often  brought  to 
the  rectal  specialist  for  diagnosis  and  treatment.  More  will  be  said 
upon  this  class  of  cases  under  the  chapters  on  Ulcerations  and  Strict- 
ure. 

There  is  also  a  distinct  follicular  proctitis  in  which  the  inflamma- 
tion in  its  first  stages  is  confined  entirely  to  the  deep  follicles.  These 
may  be  felt  as  small  nodules  in  the  substance  of  the  mucous  mem- 
brane ;  and  their  orifices,  which  are  red  and  swollen,  can  be  distinctly 
seen  with  a  speculum,  sometimes  as  many  as  three  or  four  in  the 
field  of  vision.  The  disease  is  chiefly  confined  to  the  upper  part  of 
the  rectum,  but  may  involve  also  the  sigmoid  flexure  and  descending 
colon. 

Diphtheritic  proctitis  is  a  local  manifestation  of  the  general  poison- 
ing, exactly  analogous  to  the  inflammation  of  the  air-passages,  and 


PROCTITIS    AND    PERIPROCTITIS.  67 

attended  by  the  same  production  of  membrane,  in  males  in  the 
rectum,  in  females  generally  also  in  the  vagina.  It  is  an  indication 
of  the  profound  effect  which  the  specific  poison  has  had  upon  the 
system. 

Gonorrhoeal  proctitis  in  men  is  generally  due  to  the  habit  of 
passive  paederasty  resulting  in  direct  contagion.  In  woman  it  may 
be  due  either  to  this  cause  or  to  the  inoculation  of  fissures  or  erosions 
of  the  anal  mucous  membrane  by  a  gonorrhoeal  discharge  from  the 
vagina  flowing  over  the  anus.  The  disease  is  rare  and  will  be  further 
described  under  Venereal  Affections. 

In  the  acute  variety  of  catarrhal  proctitis  the  inflammation  does 
not  extend  deeper  than  the  mucous  membrane,  which  is  congested 
and  hyper£emic.  In  the  chronic  the  inflammation  involves  the  sub- 
mucous and  muscular  layers.  The  acute  generally  ends  in  resolution 
in  from  eight  to  fourteen  da3's  where  the  cause  can  be  found  and 
removed.  It  may,  however,  in  severe  cases  go  on  to  actual  gangrene, 
and  after  extending  over  a  large  part  of  the  large  bowel  terminate 
fatall}^.  The  chronic  results  in  infiltration  and  consequent  thicken- 
ing of  the  rectal  wall,  and  may  end  in  ulceration,  either  superficial 
and  confined  to  the  epithelial  layer  of  the  mucous  membrane,  or  deep 
and  involving  the  whole  thickness  of  the  mucous  layer.  What  is 
described  as  follicular  ulceration  (ulceration  affecting  the  mouths  of 
the  tubular  follicles)  may  result  from  chronic  inflammation,  and  these 
ulcers,  which  are  very  minute  at  first,  may  coalesce  and  gain  in  depth 
till  they  cause  perforation  of  the  bowel.  When  the  perforation  is 
above  the  peritoneal  reflection  a  fatal  peritonitis  may  result ;  when 
lower  down,  an  abscess  or  flstula.  A  chronic  proctitis  may  in  this 
way  be  a  cause  of  stricture,  and  may  result  in  the  hypertrophy  known 
as  chronic  parenchymatous  proctitis. 

Under  the  head  of  simple  proctitis  should  be  included  the  great 
mass  of  so-called  syphilitic  strictures.  Their  gross  ajDpearances  are 
familiar  to  all.  By  digital  examination  a  rigid  canal  is  reached  just 
within  the  rectal  pouch.  The  walls  contract  like  a  cone  until  often 
at  the  upper  part  the  passage  of  the  finger  is  impossible.  The  upper 
part  is  fluted,  the  mucous  membrane  is  sometimes  smooth  and  mov- 
able, at  others  completely  destroyed.  The  rectum  as  a  whole  is 
movable,  and  vaginal  examination  allows  the  fibrous  mass  within  the 
rectum  to  be  felt,  biit  the  vagina  is  not  adherent  to  it.  There  are  no 
enlarged  glands. 

Under  the  microscope  the  glands  of  the  mucosa  will  be  found  to 


68  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

have  completely  disappeared.  Irregular  papillary  projections  pene- 
trate the  thickened  and  hardened  epithelium  which  rests  directly 
upon  the  subjacent  connective  tissue,  it  being  impossible  to  dis- 
tinguish what  appertains  to  the  chorion  of  the  mucosa  or  to  the 
cellular  layer.  The  epithelium  has  changed  from  the  cylindrical  to 
the  stratified  pavement  variety  and  taken  on  the  Malpighian  type. 
In  the  deeper  parts  is  seen  a  process  of  hardening,  and,  in  general, 
a  thickened  layer,  completely  hardened,  where  the  cellular  contours 
have  disappeared.  At  some  points  the  mucous  membrane  is  adher- 
ent. The  epithelium  rests  directly  on  the  subjacent  fibrous  tissue. 
There  are  neither  muscularis  mucosae  nor  glands.  Between  the 
epithelium  and  the  muscular  layer,  dense  fibrous  bundles  are  seen, 
heavily  charged  with  embryonal  cells.  At  certain  points  these  fibrous 
bundles  appear  gathered  around  the  blood-vessels.  Embryonic  cells, 
strongly  colored  by  the  reagents,  exist  in  abundant  masses  in  the 
lymph-spaces  which  separate  the  fibrous  bundles  and  around  nearly 
all  of  the  blood-vessels,  which  are,  moreover,  rare  in  the  fibrous 
thickening  and  only  capillary,  their  endothelium  being  tumefied,  the 
nuclei  of  the  endothelial  cells  very  marked  and  brightly  colored  by 
reagents.  In  the  peripheral  portions  the  unstriped  muscular  fibres 
show  no  changes,  but  the  vessels  in  this  layer  or  bej^ond  are  altered 
and  the  endothelium  of  the  arteries  is  somewhat  proliferated.  Both 
arteries  and  veins  are  surrounded  by  considerable  embryonic  masses. 

In  other  words,  we  have  to  do  with  an  inflammatory  affection 
characterized  by  a  perivascular  sclerosis  with  complete  disappear- 
ance of  the  glands  of  the  mucous  membrane  and  transformation  of 
epithelium. 

That  syphilis  plays  any  role  in  the  causation  of  such  a  stricture 
I  cannot  believe.  In  the  first  place  many  of  these  patients  have  never 
had  any  manifestation  of  syphilis  unless  this  be  syphilis,  and  if  this 
be  syphilis  it  is  often  the  first,  last,  and  only  symptom  of  the  disease. 
I  do  not  refer  now  to  patients  who  deny  syphilis  either  from  igno- 
rance or  from  design,  but  to  women  and  phj'sicians  in  whom  to  sus- 
pect syphilis  is  to  disregard  all  rules  of  evidence  and  common  sense. 

In  the  second  place,  this  condition  never  yields  to  either  mercury 
or  iodine.  To  account  for  this  it  is  customary  to  say  that  the  treat- 
ment is  undertaken  too  late.  But  why  is  it  always  too  late  ?  The 
cases  are  seen  early,  for  thej^  are  attended  by  great  pain  and  suffer- 
ing. They  wander  from  doctor  to  doctor  and  often  give  a  history 
of  prolonged  antisyphilitic  treatment,  but  are  never  relieved  by  it. 


PEOCTITIS    AND    PERIPROCTITIS.  69 

In  tlie  tliird  place,  in  no  other  organ  of  the  body  are  true  syphi- 
litic lesions  ever  found  at  all  comparable  to  this  one.  Sj^pliilis  does 
cause  stricture  of  the  larynx,  trachea,  and  perhaps  also  oesophagus, 
but  these  contractions  are  due  to  the  cicatrization  of  lesions  primarily 
ulcerative,  tlie}^  are  irregular  cicatrices  and  salient  bands  which  de- 
form the  organ  and  in  no  way  resemble  tlie  regular  conical  stricture 
of  the  rectum  due  to  hypertrophy  and  sclerosis  which  we  are  con- 
sidering. If  this  stricture  be  syphilitic  it  is  a  lesion  peculiar  to  the 
rectum  and  unique  in  the  history  of  syphilis. 

The  symptoms  of  proctitis  in  the  acute  form,  are  a  sensation 
of  heat  and  weight  in  the  part  which  may  amount  to  actual  pain, 
and  may  involve  the  bladder,  uterus,  and  sacral  region,  and  radiate 
into  the  loins  and  down^the  thighs.  The  anus  also  becomes  painful, 
red,  and  contracted,  and  in  children  the  mucous  membrane  may  be- 
come slightly  everted  from  the  swelling  and  tenesmus.  The  evacua- 
tions soon  become  painful  and  increased  in  number,  and  the  faeces 
are  streaked  with  mucus,  blood,  and  pus.  There  is  aj)t  to  be  also  a 
train  of  symptoms  referable  to  the  bladder  and  to  the  generative  or- 
gans, such  as  painful  micturition,  cystitis,  and  leucorrhoea. 

With  these  local  symptoms  there  may  be  more  or  less  constitu- 
tional disturbance,  fever,  and  loss  of  appetite.  As  the  discharge 
from  the  iniiamed  surface  increases  in  amount,  the  desire  to  empty 
the  rectum  produces  more  frequent  evacuations,  so  that  while  at  first 
the  faeces  are  only  stained  with  pus  and  blood,  later  the  evacuations 
consist  entirely  of  the  muco-purulent  matter,  and  the  anus  may 
become  excoriated  by  the  discharge. 

In  the  chronic  form  the  symptoms  are  all  less  marked.  The 
diarrhoea  may  alternate  with  constipation,  and  the  discharge  will 
occur  only  at  the  time  of  defecation.  This  condition  may  last  for 
years.  An  examination  of  the  rectum  during  the  acute  stage  of 
proctitis  will  generally  cause  considerable  pain.  The  rectal  mucous 
membrane  will  be  found  intensely  congested,  and  the  temperature, 
as  shown  by  the  thermometer  or  even  by  the  finger,  will  be  increased. 
In  the  chronic  stage  the  solitary  glands  may  occasionally  be  recog- 
nized as  small  round  prominences  in  the  substance  of  the  mucous 
membrane. 

Proctitis  is  generally  found  associated  with  stricture  of  the 
rectum  and  may  be  either  the  direct  cause  of  it  or  a  secondary  result 
of  it.  In  the  latter  cases  the  mucous  membrane  below  the  stricture 
will  be  found  congested  and  covered  with  pus  or  bloody  mucus, 


70  SURGERY    OF   THE    llECTU^    AND    PELVIS. 

while  above  it  is  eroded  and  destroyed,  sometimes  only  superficially, 
at  others  for  its  entire  depth.  The  other  layers  will  be  found  hyper- 
trophied,  especially  the  circular  muscular  layer. 

The  treatment  of  proctitis  consists  first  of  all  in  an  endeavor  to 
discover  and  remove  the  cause  of  the  congestion,  be  it  what  it  may. 
If  hemorrhoids  are  at  the  bottom  of  the  trouble  they  must  be  re- 
moved, and  the  same  with  polypus.  In  the  cases  associated  with 
uterine  disease  it  may  be  necessary  to  first  turn  the  attention  to  this 
organ  and  rectify  a  displacement  or  operate  upon  a  lacerated  cervix. 

In  treating  the  proctitis  itself  both  local  and  general  measures 
may  be  adopted.  Absolute  rest  in  bed,  with  a  diet  of  milk,  meat, 
and  eggs,  which  leaves  the  least  possible  amount  of  fecal  residue, 
should  be  strictly  enforced.  The  bowels  should  be  moved  by  saline 
cathartics  in  small  doses  to  produce  semi-solid  stools,  or  by  the  com- 
pound licorice  powder.  In  the  acute  stage  the  pain  and  tenesmus 
may  best  be  treated  by  injections  of  starch  water,  bismuth,  and 
opium,  given  in  doses  small  enough  to  be  retained.  The  use  of  the 
speculum  or  suppositories  should  be  avoided  on  account  of  the 
pain  caused  by  their  introduction. 

In  the  chronic  stage  astringents  are  necessary,  and  sulphate  of  zinc, 
tannin,  and  nitrate  of  silver  may  each  be  tried.  If  the  spot  of  diseased 
mucous  membrane  can  be  reached  through  a  speculum,  it  may  be 
painted  with  a  five-  or  ten  grain  solution  of  nitrate  of  silver  and  a 
brush.  If  the  disease  covers  more  surface,  an  injection  of  a  solution 
of  nitrate  of  silver  (grs.  ij.-3  i.)  will  more  likely  come  in  contact  with 
the  whole  affected  part,  and  this  should  be  followed  immediately  by. 
a  more  copious  enema  of  warm  water.  Such  an  application  should 
not  be  made  oftener  than  every  third  day.  For  the  treatment  of  the 
ulceration  and  stricture  resulting  from  this  disease  the  reader  is  re- 
ferred to  the  appropriate  chapters. 

Perifproctitis  occurs  in  several  distinct  varieties,  the  most  serious 
of  which  is  of  septic  origin,  is  dift'use  and  not  circumscribed,  and  is 
the  chief  cause  of  death  after  surgical  operations  upon  the  rectum. 
I  have  fortunately  met  it  but  few  times,  though  I  have  seen  it  follow 
the  division  of  a  small  fistula  in  hospital  and  end  fatally. 

Even  with  very  diffuse  inflammation  death  may  not  always  be  the 
immediate  result.  In  one  case  of  internal  proctotomy  for  stricture 
the  chill  and  inflammation  set  in  at  the  usual  time,  when  it  comes  at 
all — about  the  third  day.  In  this  case  I  had  great  hopes  of  saving 
the  patient,   as  the  abscess  was  plainly  visible  in  the  ischio-rectal 


PROCTITIS   ATSTD    PERIPROCTITIS.       '  71 

fossa  and  was  freely  cut.  Large  masses  of  black,  sloughing  cellular 
tissue  were  discharged  through  the  incisions,  but  no  healthy  pus. 
In  a  few  days  openings  formed  between  the  abscess  and  the  rectum. 
The  patient  dragged  on  for  several  months,  but  there  was  never  any 
healthy  reparative  action,  and  he  was  finally  worn  out  by  repeated 
hemorrhages  from  the  erosion  of  small  vessels  and  by  a  communica- 
tion formed  between  the  rectum  and  bladder.  On  the  autopsy  there 
seemed  to  be  no  part  of  the  pelvis  whicli  had  not  been  invaded  by 
the  disease. 

I  have  also  seen  a  cold  abscess  form  around  a  cancerous  stricture 
without  giving  rise  to  any  symptoms,  and  progress  till  death  re- 
sulted in  exactly  the  same  way — exhaustion  and  opening  into  the 
bladder. 

This  is  the  complication  which,  in  spite  of  antisepsis,  sometimes 
occurs  after  operations  upon  the  rectum,  and  whicli  it  is  the  one 
object  of  the  surgeon  to  avoid.  In  the  acute  form  it  is  analogous  to 
puerperal  septicsemia.  In  its  general  symptoms  it  follows  closely 
the  clinical  history  of  pygemia. 

In  the  way  of  prophylaxis  much  may  be  done  by  antisepsis 
during  and  after  all  operations  on  the  rectum.  There  is  no  operation 
on  the  rectum  too  trivial  to  be  done  with  care  and  cleanliness ;  and 
yet  the  capital  operations  which  are  now  matters  of  daily  occurrence 
show  what  results  may  be  obtained  by  proper  attention  to  these 
details.  This  is  not  the  place  to  go  into  the  details  of  each  surgical 
operation,  but  I  have  learned  the  greatest  single  element  in  prophy- 
laxis to  be  the  careful  attention  to  all  antiseptic  precautions.  A  cut 
should,  moreover,  never  be  made  through  the  rectal  wall  into  the 
cellular  tissue  without  at  the  same  time  allowing  for  the  free  escape 
of  all  the  discharge  from  such  a  cut  by  a  division  of  the  sphincters. 

In  the  way  of  treatment  for  periproctitis,  life  may  be  saved  by  free 
incisions  and  antiseptic  irrigations  where  the  inflammation  shows 
any  tendency  to  become  circumscribed  ;  but  otherwise  the  disease  is 
fatal. 

Gangrenous  Cellulitis. — There  is  a  form  of  gangrenous  cellulitis 
which  sometimes  affects  the  ischio-rectal  region.  It  is  a  rare  disease 
and  is  generally  idiopathic.  In  it  there  is  no  pus  formed,  but  the 
cellular  tissue  and  the  skin  over  it  become  necrosed  and  slough  in 
large,  black  masses.  The  adjacent  portion  of  the  rectal  wall  may  be 
involved  and  the  rectum  be  laid  open  for  a  considerable  extent.  The 
disease  is  attended  with  fever  and  great  prostration  ;  the  tendency  to 


72  SURGEEY   OF   THE   RECTUM    AND   PELVIS. 

relapse  and  extension  is  marked,  and  the  cavit}^  left  after  separation 
of  the  slough  closes  very  slowly.  Jordan,  who  has  given  a  short 
clinical  report  of  a  few  cases,  has  always  seen  it  in  large,  heavy  men 
who  eat  too  much  and  drink  heavily.  In  such,  a  very  slight  irrita- 
tion, such  as  is  caused  by  sitting  on  a  wet  seat,  is  sufficient  to  start 
the  trouble.  These  cases  not  infrequently  end  fatally  from  extension 
of  the  gangrene  into  the  pelvis,  or  exhaustion.  The  treatment  con- 
sists in  early  and  free  incisions  and  in  supporting  the  powers  of  the 
patient. 

The  other  forms  of  periproctitis— those  which  are  not  due  to  sur- 
gical operations  and  are  distinctly  circumscribed— will  be  treated  of 
under  the  head  of  Abscess. 


CHAPTER  YI. 

ABSCESS. 

Abscesses  in  the  region  of  the  anus  and  rectum  are  best  classi- 
fied according  to  their  anatomical  location  into  superficial,  ischio- 
rectal, and  pelvic.  Of  each  of  these  there  are  several  different 
varieties. 

Considering  first  the  superficial  variety,  the  simplest  form  will  be 
found  to  be  that  which  involves  the  skin  of  the  margin  of  the  anus 
alone,  and  which  generally  originates  in  one  of  the  minute  glands  of 
the  part.  Such  an  abscess  may  be  due  to  traumatism,  or  to  any 
irritation — such  as  the  use  of  improper  paper  after  defecation,  pro- 
longed walking  or  horseback  riding,  a  menstrual  discha.rge,  or  a  dis- 
charge due  to  diarrhoea  or  dysentery — to  suppuration  beneath  an 
inflamed  pile,  or  to  the  presence  of  a  caseating  tubercular  nodule. 
I  have  several  times  seen  it  follow  injections  of  carbolic  acid  into 
hemorrhoids,  the  pus  forming  beneath  the  mucous  and  muscular 
layers  and  burrowing  downward  to  the  anus  till  it  lay  superficially 
over  the  sphincter. 

This  form  of  disease  is  always  distinctly  circumscribed,  is  gen- 
erally about  the  size  of  an  almond,  is  found  by  preference  in  robust 
persons,  more  often  in  men  than  women,  seldom  in  old  people,  and 
almost  never  in  children.  It  generally  goes  on  rapidly  to  suppura- 
tion, breaks  spontaneously  on  the  cutaneous  or  mucous  surface,  and 
heals  without  the  formation  of  fistula  ;  though  in  cachectic  patients  it 
may  pursue  a  contrary  course,  the  skin  over  it  becoming  thin  and 
violet-colored,  and  finally  rupturing,  leaving  a  permanent  sub- 
cutaneous fistula,  which  by  subsequent  burrowing  may  reach  a 
considerable  size.  Such  is  apt  to  be  the  course  in  the  cases  arising 
from  the  injection  of  carbolic  acid. 

The  treatment  of  such  an  abscess  consists  chiefly  in  the  attempt 
to  avoid  the  formation  of  a  fistula,  and  the  best  means  for  accom- 
plishing this  end  is  an  early  incision  as  soon  as  suppuration  appears 


74  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

inevitable.  Resolution  is  hardly  to  be  expected,  but  it  may  be 
sought  for  by  the  use  of  laxatives,  rest  in  the  horizontal  posture,  and 
the  application  of  a  bladder  of  ice.  The  incision  should  be  large 
enough  to  allow  of  the  free  exit  of  pus,  and  after  it  has  been  made 
the  part  may  be  poulticed  for  a  day  or  two,  and  the  abscess  cavity 
then  dressed  with  lint,  care  being  taken  to  keep  the  lips  of  the  in- 
cision separated. 

Another  frequent  cause  of  superficial  abscess  is  the  acute  in- 
flammation and  suppuration  of  an  external  hemorrhoid,  which  gener- 
ally comes  on  after  an  attack  of  constipation  and  straining  at  stool, 
or  may  be  due  to  the  same  causes  as  the  last.  The  suffering  caused 
by  such  a  condition,  as  by  the  one  last  described,  is  out  of  all  pro- 
portion to  its  apparent  importance,  and  is  sufficient  to  incapacitate 
a  person  of  sensitive  organization  from  all  accustomed  duties.  The 
remains  of  former  external  hemorrhoids  are  always  liable  to  this  ac- 
cident, and  by  the  proper  abortive  treatment  the  inflammation  may 
sometimes  be  overcome  without  suppuration.  If,  however,  suppura- 
tion appears  to  be  inevitable,  a  small,  sharp-pointed  bistoury  should 
be  quickly  passed  through  the  little  tumor. 

There  is  also  a  form  of  superficial  abscess  which  lies  nearer  to  the 
mucous  membrane  than  the  skin,  and  is  due  to  the  acute  inflamma- 
tion of  an  internal  hemorrhoid,  either  just  at  the  verge  of  the  anus 
or  within  the  sphincter.  This  is  in  reality  a  circumscribed  phlebitis 
in  a  venous  pouch  which  is  shut  off  from  the  general  circulation.  A 
circumscribed,  tense,  exquisitely  painful  tumor  is  formed,  varying  in 
size  from  a  grape  to  an  almond,  which,  after  a  few  days  of  suffering, 
ruptures  spontaneously  and  allows  the  escape  of  a  small  quantity  of 
pus.  Such  an  abscess,  when  within  the  bowel,  is  always  liable,  as 
will  be  shown  later,  to  result  in  the  formation  of  a  blind  internal  flstula 
or  of  a  chronic  ulcer  if  left  to  its  own  course,  and  should,  therefore, 
be  treated  by  early  incision. 

There  is  still  another  variety  of  superficial  abscess,  more  serious 
in  its  consequences  than  those  already  described,  for  the  reason  that 
it  affects  the  subcutaneous  tissue  and  not  the  skin,  and  is  diffuse  and 
not  circumscribed.  The  symptoms  of  this  form  of  disease  vary 
greatly  in  different  cases.  In  cachectic  persons  pus  may  form  in  large 
quantity  and  break  into  the  bowel  with  very  slight  local  or  general 
symptoms,  and  a  blind  internal  fistula  may  result.  The  diagnosis  is 
generally  easy.  There  will  be  the  usual  pain,  tenderness  and  swell- 
ing ;  and,  if  the  pain  be  not  too  severe  to  admit  of  the  attempt,  flue- 


ABSCESS-  75 

tuation  may  be  obtained  by  introducing  one  finger  into  tlie  rectum 
and  making  counter-pressure  with  the  other  hand  outside. 

There  is  little  use  in  hoping  for  resolution  in  an  abscess  of  this 
kind,  and  all  active  attempts  to  cause  it  will  be  found  to  do  harm 
rather  than  good.  The  proper  treatment  is  an  early  free  incision.  If 
pus  has  already  formed  or  the  skin  has  begun  to  grow  thin  over  the 
abscess  cavity,  the  incision  should  be  free  enough  to  allow  of  the 
easy  escape  of  the  contents,  for  in  this  way  only  can  the  formation 
of  a  fistula  be  avoided.  In  such  a  case  drainage  should  be  resorted 
to  after  the  incision,  and  every  effort  should  be  made  to  secure  heal- 
ing from  the  bottom  of  the  cavity. 

Iscliio-rectal  Abscess. — An  abscess  of  the  ischio-rectal  fossa  is 
bounded  by  the  levator  ani  miiscle  superiorly,  and  by  the  skin 
below,  with  the  rectum  on  one  side  and  the  adjacent  portion  of  the 
pelvis  on  the  other. 

The  causes  of  ischio-rectal  abscess  are  various.  Traumatism  in 
some  form  accounts  for  many,  and  the  injury  may  be  either  from 
within  or  without.  Kicks,  falls,  wounds  by  the  point  of  a  syringe, 
perforation  of  the  bowel  by  pins  and  fish  bones,  operations  for 
hemorrhoids,  and  injections  of  carbolic  acid  into  them,  have  all  been 
followed  by  this  complication.  They  may  also  result  from  rupture, 
ulceration,  or  perforation  of  the  rectal  wall  in  connection  with  strict- 
ure. Finally,  they  may  be  due  to  a  tubercular  deposit  in  the  wall 
of  the  gut  which  has  softened  and  caused  perforation.  This  is  a  fre- 
quent cause  of  blind,  internal  fistulse. 

An  abscess  of  the  ischio-rectal  fossa  shows  itself  with  all  the 
usual  symptoms  of  acute  inflammation  and  can  hardly  be  mistaken 
for  anything  else.  It  may  begin  with  chill  and  considerable  con- 
stitutional disturbance,  there  will  be  severe  pain,  and  the  skin  will 
be  hard,  red,  and  cedematous  sometimes  over  a  considerable  part  of 
the  buttock.  The  pus,  if  allowed  to  take  its  own  course  (which  it 
never  should  be),  generally  finds  its  way  both  to  the  cutaneous  and 
mucous  surfaces,  and  a  complete  and  deep  fistula  results.  It  may, 
however,  tend  upward  in  the  perineum,  being  less  confined  in  that 
direction,  and  the  prostate  and  urethra  may  be  pressed  upon,  causing 
retention  of  urine.  Retention  of  urine  is  by  no  means  an  uncommon 
result  of  this  condition,  and  I  have  known  it  to  result  fatally  before 
its  existence  was  even  suspected. 

The  prognosis  of  ischio-rectal  abscess  depends  almost  absolutely 
upon  the  treatment   adopted.      If  it  be  poulticed   and  allowed  to 


76  SURGEEY    OF    THE   EECTU3I    A^'D    PELVIS. 

take  its  own  course;  a  fistula  of  greater  or  less  extent  is  tlie  certain 
result. 

There  is  but  one  proper  treatment  for  tliis  form  of  trouble,  and 
that  is  an  early  and  free  use  of  the  knife.  It  may  be  considered  a 
rule  that  an  acute  infiammation  in  this  region  will  go  on  to  suppura- 
tion, and  hence  that  antiphlogistic  measures  adopted  with  a  view  of 
securing  resolution  are  useless.  As  soon  as  the  hard,  brawny  swell- 
ing appears,  therefore,  and  without  waiting  for  the  pointing  of  pus, 
it  should  be  freely  and  deeply  incised.  Ether  will  be  necessary  to 
perform  this  operation  properly.  A  long,  fine,  straight  bistoury 
should  be  inserted  into  the  centre  of  the  swelling  and  pushed  for- 
ward till  pus  issues  by  the  side  of  the  blade.  It  may  be  necessary  to 
carry  the  point  fully  four  inches  upward  and  to  repeat  the  puncture 
more  than  once  befoj-e  pus  is  found.  Then  make  an  incision  from 
two  to  three  inches  in  length  through  skin  and  cellular  tissue.  Into 
this  the  index  finger  should  be  passed,  all  sloughing  tissue  should 
be  broken  down,  and  all  pockets  opened  up  till  it  is  certain  that  a 
free  communication  of  all  parts  of  the  abscess  with  the  external 
wound  has  been  established.  Wash  out  the  abscess  cavity  with  a 
solution  of  bichloride  1  to  2,000  till  no  more  pus  or  debris  can  be  seen 
in  the  returning  injection.  The  cavity  should  be  packed  with  iodo- 
form gauze  and  tlie  wound  dressed  antiseptically.  After  a  few  days 
of  antiseptic  dressing  the  surgeon  can  judge  whether  the  cavity  is 
closing  promptly  or  whether  the  case  is  to  be  a  long  one,  only  heal- 
ing by  a  slow  process  of  granulation.  In  the  former  condition  the 
antiseptic  dressings  may  be  continued  till  healing  is  complete  ;  in  the 
latter  they  may  as  well  be  abandoned  and  the  cavity  left  to  its  own 
course,  care  being  taken  to  prevent  burrowing  by  drainage  and  free 
escape  of  pus.  Though  by  this  line  of  treatment  I  have  frequently 
avoided  the  formation  of  fistula,  I  have  not  had  much  success  in  se- 
curing rapid  closure  of  the  abscess  cavity,  and  healing  has  usually 
required  many  weeks.  Should  another  opening  form  after  a  free  in- 
cision, as  it  sometimes  will,  the  surgeon  need  not  reproach  himself. 
Pus  often  has  a  way  of  finding  its  own  exit  in  spite  of  any  -plain 
road  which  may  be  laid  out  for  it  with  a  knife. 

These  abscesses  should  not  at  first  be  laid  open  into  the  rectum. 
unless  they  have  come  vevy  near  to  the  rectal  surface — a  point 
which  is  generally  misunderstood  in  practice  because  of  the  con- 
founding of  an  abscess  which  may  ultimately  result  in  a  fistula 
with    fistula   itself.      The    treatment    is    that    of   abscess,   and    not 


ABSCESS.  77 

that  of  fistula,  and  is  especiall}^  directed  toward  the  prevention  of 
fistula. 

Should  the  abscess  have  been  neglected  till  it  has  opened  exter- 
nally, it  is  still  essentially  an  abscess  and  not  a  fistula,  and  the  treat- 
ment described  may  still  be  carried  out  with  a  fair  prospect  of  suc- 
cess in  avoiding  an  opening  into  the  bowel.  I  wish  to  emphasize 
this  point  strongly,  for  I  have  seen  very  unfortunate  results  follow 
free  division  of  both  sphincters  for  deep  abscess,  and  it  is  a  step 
which  should  always  be  avoided  if  possible.  That  it  is  possible  in 
this  class  of  cases  I  have  occasionally  proved  to  my  own  satisfaction, 
and  I  do  not  hesitate  now  to  try  every  means  with  which  I  am  ac- 
quainted, at  any  cost  of  time  to  the  patient,  before  resorting  to  the 
usual  plan  of  dividing  everything  between  the  abscess  cavity  and  the 
bowel. 

If,  however,  the  case  has  been  neglected  till  an  internal  opening 
has  formed  and  the  skin  over  the  ischio-rectal  fossa  has  also  become 
perforated — if,  in  other  words,  several  days  or  even  weeks  have  gone 
by — the  abscess  will  ^Drobably  have  to  be  laid  open  into  the  gut  to 
secure  satisfactory  healing.  The  rule  of  practice  must  depend  upon 
the  amount  of  tissue  between  the  abscess  and  the  cavity  of  the  gut. 
If  there  is  enough  of  this,  so  that  there  is  a  fair  chance  that  perfor- 
ation will  not  occur,  the  case  is  to  be  treated  simply  as  an  abscess 
and  independently  of  the  gut.  If,  on  the  other  hand,  perforation  is 
probable,  the  case  may  be  treated  as  a  fistula  from  the  outset,  as 
fistula  is  sure  to  occur.  Of  course,  errors  in  judgment  may  occur, 
and  a  second  operation  may  on  this  account  become  necessary. 

Deeip  Pelvic  Abscess. — The  levator  ani  muscle  forms  a  true  dia- 
phragm to  the  pelvis.  Pus  which  forms  below  it  is  easih^  evacuated 
by  the  knife  or  discharges  spontaneously  upon  the  surface  of  the 
perineum  or  within  the  rectum,  and  although  incurable  fistulc3e  may 
result,  life  is  seldom  endangered. 

Between  this  diaphragm  of  the  pelvis  and  the  peritoneum  which 
is  in  relation  with  it  on  the  pelvic  side,  there  is  a  considerable  space 
filled  with  loose  connective  tissue. 

Abscesses  in  this  location  may  assume  vast  proportions,  burrowing 
laterally  into  the  subperitoneal  connective  tissue  of  the  iliac  fossae, 
or  almost  anywhere  else  in  the  true  pelvis  ;  discharging  into  the  blad- 
der, or  rectum  high  up  ;  mounting  above  the  bladder  or  pointing  in 
the  groin  or  loin,  passing  downward  out  of  the  pelvis  into  the  thigh, 
and  causing  retention  of  urine  or  intestinal  obstruction  by  pressure. 


to  SUKGEKY  OF  THE  RECTUM  AND    PELVIS. 

Pelmc  Abscess  in  the  il/aZe.— These  abscesses  are  due  to  tlie  same 
causes  as  those  last  described  and  to  some  others.  They  may  be  sec- 
ondarj'^  to  diseases  of  the  urinary  organs,  such  as  gonorrhoea,  acute 
inflammation  of  the  prostate,  or  rupture  of  the  urethra  and  extrava- 
sation of  urine. 

Tlie  perforation  of  the  gut  by  a  rectal  bougie  or  by  the  point  of  a 
syringe,  and  the  landing  of  an  enema  in  the  perirectal  cellular  tissue, 
will  set  up  this,  form  of  disease.  It  may  be  a  result  of  appendicitis, 
and  it  may  be  in  its  origin  entirely  disconnected  with  tlie  rectum, 
and  due  to  disease  of  some  neighboring  part,  or  to  necrosis  of  some 
adjacent  bone  of  the  pelvis  or  spine.  In  the  latter  case,  the  abscesses 
are  generally  of  the  variety  known  as  cold  abscess,  and  are  apt  to 
be  preceded  for  a  long  time  by  pain  at  the  point  of  disease  in  the 
bone.  These  may  be  diagnosticated  by  microscopic  examination  of 
the  pus  discharged  and  a  search  for  bone  debris. 

The  symptoms  are  often  obscure  and  far  from  characteristic. 
There  is  more  or  less  vague  pain  in  the  pelvis  and  lumbar  region, 
which  is  seldom  intense  and  generally  increased  by  defecation.  Fever 
may  be  entirely  absent,  is  seldom  continuous,  and  chills  are  only 
occasionally  met  with  when  pus  is  formed.  On  the  other  hand,  the 
patient  may  soon  sink  into  a  typhoid  condition  Avith  high  tempera- 
ture and  diarrhoea.  Vesical  symptoms  are  more  marked  than  intes- 
tinal ones,  for  there  is  apt  to  be  great  vesical  irritation  with  incon- 
tinence or  retention  of  urine.  There  are  but  two  ways  of  making  the 
diagnosis.  The  first  is  by  examination  of  the  rectum  and  discovery 
of  the  phlegmon  ;  the  second  is  b}^  finding  that  the  joatient  has  evacu- 
ated a  large  quantity  of  fetid  pus  by  the  rectum  or  bladder.  The 
same  condition  in  the  female  leads  naturally  to  a  pelvic  examination, 
but  I  have  known  a  man  to  wander  from  one  hospital  to  another  for 
weeks  without  examination  and  hence  without  diagnosis. 

Even  when  the  diagnosis  of  the  existence  of  the  condition  has 
been  made,  it  maybe  impossible  for  a  time  to  determine  its  origin,  for 
psoas  abscess,  abscess  from  hip  disease,  periproctitis,  and  perinephri- 
tis may  each  cause  a  collection  of  pus  in  the  pelvis. 

The  prognosis  is  necessarily  grave.  In  the  beginning  the  patient 
is  exposed  to  all  the  dangers  of  septicaemia,  and  the  immediate  re- 
sults being  favorable  the  ultimate  ones  may  still  be  disastrous,  being 
those  which  always  attend  upon  prolonged  suppuration— chronic  in- 
validism, visceral  complications,  anyloid  degeneration  of  the  liver 
and  kidneys,  and  tubercular  deposits.     In  the  comparatively  small 


ABSCESS.  79 

number  of  cases  in  which  spontaneous  healing  occars  the  patient 
still  may  have  to  meet  the  results  of  extensive  cicatiicial  contraction. 
There  may  be  stricture  on  the  one  hand  or  incontinence  on  the  other. 
The  rectal  stenosis  may  be  so  great  as  to  cause  complete  obstruction. 

Regarding  the  termination  of  these  abscesses,  Segoud  has  collected 
important  statistics.  Thirty-five  perforated  the  urethra,  and  seventy- 
seven  other  parts  ;  generally  the  rectum,  but  occasionally  the  peri- 
neum, the  ischio- rectal  fossa,  and  the  obturator  foramen.  Twenty 
per  cent,  are  fatal,  and  many  leave  fistulous  communications  with 
the  urethra  or  rectum  which  are  never  cured. 

The  treatment  of  deep  abscess  in  men  may  now  be  described  in 
two  words — incision  and  drainage.  The  incision  should  be  made  as 
soon  as  the  diagnosis  of  the  presence  of  pus  is  reasonably  estab- 
lished. It  is  true  that  these  abscesses  tend  naturally  to  discharge 
themselves  into  the  rectum  or  bladder,  and  that  by  waiting  for  this 
an  operation  may  often  be  avoided  ;  but  this  by  no  means  constitutes 
a  cure,  rather,  on  the  contrary,  a  life  of  chronic  invalidism.  If  the 
pus  be  approaching  the  surface  through  the  perineum,  the  incision 
should  be  made  here  ;  if  toward  the  rectum,  it  should  be  met  through 
that  cavity  ;  should  it  appear  in  tlie  groin  or  thigh,  free  incisions 
must  be  made  for  its  outlet ;  and  should  a  tumor  arise  in  the  iliac 
fossa  or  above  the  bladder,  the  operation  must  be  done  through  the 
abdomen.  The  incision  must  be  free  enough  to  allow  of  the  escape 
of  all  the  contents,  washing  out  the  abscess  cavity,  and  the  estab- 
lishment of  thorough  drainage. 

Zeller  has  advocated  a  perineal  incision  whenever  possible,  even 
after  pointing  has  taken  place  into  the  rectum.  He  objects,  very 
properly,  to  the  incision  into  the  rectum  that  it  is  too  small,  does 
not  tap  the  abscess  at  the  most  dependent  part,  is  not  free  from  risk 
of  hemorrhage,  and  does  not  prevent  the  formation  of  urethro-rectal 
fistula,  which  is  much  more  intractable  than  urethro-perineal  fistula. 
From  my  own  experience  I  should  judge  that  to  reach  pus  by  a 
perineal  incision  would  seldom  be  practicable,  and  yet  I  have  seen  a 
free  opening  into  the  rectum  refuse  to  heal  in  spite  of  dilatation  and 
drainag-e. 


CHAPTER  YII. 

PELVIC  ABSCESS   IN  WOMEN. 

Many  of  the  causes  already  enumerated  as  acting  to  produce 
pelvic  abscesses  in  men  are  also  effective  in  vi^omen,  but  their  influence 
is  hardly  to  be  considered  in  comparison  with  the  two  great  causes — 
septic  and  gonorrhoeal  inflammation,  extending  from  the  endometrium 
through  the  Fallopian  tube,  to  the  pelvic  peritoneum.  As  a  rule 
there  is  no  pelvic  cellulitis,  and  hence  no  pelvic  abscess,  not  preceded 
by  a  peritonitis  ;  and  hence  the  consideration  of  pelvic  abscess  in 
women  includes  the  considei'ation  of  all  that  group  of  conditions 
which  make  up  so  large  a  proportion  of  what  is  called  the  "diseases 
of  women" — salpingitis,  pyosalpinx,  abscess  of  the  ovary,  pelvic 
peritonitis,  pelvic  cellulitis,  perimetritis,  and  parametritis. 

The  two  most  frequent  exciting  causes  of  pelvic  abscess  in  women 
are  gonorrhoea  and  septic  poisoning  following  the  puerperal  con- 
dition. Both  of  these  act  by  setting  up  first  an  endometritis  which 
extends  by  direct  continuity  to  the  Fallopian  tube,  thence  to  the 
pelvic  peritoneum,  and  finally  to  the  pelvic  cellular  tissue.  The 
amount  of  inflammation  excited,  the  extent  to  which  it  reaches,  and 
the  number  of  structures  involved  in  its  course,  depend  entirely 
upon  the  virulence  of  the  infection. 

It  can  hardly  be  denied  also  that  there  is  a  class  of  post-partum 
pelvic  inflammations  in  which  no  such  direct  extension  of  the  inflam- 
mation can  be  demonstrated — cases  so  acute  and  so  virulent  that 
death  supervenes  within  a  few  days,  and  in  which  the  septic  poison- 
ing seems  to  be  directly  from  the  endometrium  to  the  body  of  the 
uterus,  the  pelvic  peritoneum,  and  the  cellular  tissue  through  the 
lymphatics. 

When  the  inflammation  extends  into  the  pelvic  cellular  tissue 
there  is  an  efi'usion  of  inflammatory  products,  which  may  subse- 
quently undergo  absorption  or  break  down  into  suppuration. 
Whether  these  abscesses  are  original!}^  extraperitoneal,  or  whether 


Fig.  45. — Pelvic  Abscess  in  Female,  Causing  Stricture  of  the  Ructum  and  Intestinal  Obstruction. 
6 


82  SURGEEY  OF  THE  RECTUM  AND  PELVIS, 

in  every  case  the  abscess  is  lirst  formed  within  the  peritoneal  cavity 
and  subsequently  extends  to  the  extraperitoneal  cellular  tissue,  is  a 
point  which  has  been  much  discussed.  Doubtless  it  is  true  that  in 
the  great  majority  of  cases  pus  is  only  found  in  the  cellular  tissue 
as  a  direct  extension  from  a  focus  of  suppuration  which  is  anatomic- 
ally within  the  peritoneal  cavity.  The  suppuration  after  once  in- 
vading the  cellular  tissue  may  extend  to  any  part  of  the  pelvis ;  and, 
as  in  the  male,  may  find  an  exit  at  a  point  far  removed  from  the 
original  point  of  infection.  These  abscesses  when  they  open  spon- 
taneously generally  do  so  into  the  rectum,  vagina,  or  bladder  ;  but 
there  is  no  limit  to  their  burrowing,  and  they  may  open  at  any  point 
between  the  thorax  and  the  thigh. 

The  symptoms  of  pelvic  abscess  in  women,  though  perhaps  not 
more  marked  than  in  men,  are  much  better  appreciated,  for  the  reason 
that  the  disease  has  been  more  carefully  studied  and  its  dependence 
upon  uterine  disease  is  better  understood.  TLey  are  those  of  pelvic 
inflammation,  beginning  generally  with  gonorrhoea  or  puerperal  sep- 
sis, and  going  on  to  hemorrhage,  fever,  pain,  and  uterine  discharge, 
with  chill,  rapid  pulse,  tender  and  swollen  pelvis,  and  the  well-known 
signs  of  septic  poisoning.  By  the  symptoms  alone  it  is  impossible  to 
tell  to  what  extent  the  inflammation  may  have  extended  and  exactly 
what  structures  are  involved.  Whether  we  have  to  deal  with  a  sal- 
pingitis, an  abscess  of  the  ovary,  or  a  peritonitis  and  abscess  of  the 
connective  tissue,  can  only  be  determined  by  physical  examination, 
or  by  waiting  till  a  discharge  of  pus  at  some  point  makes  the  diagno- 
sis clear.  Fortunately,  in  women  suffering  with  these  symptoms,  an 
examination  of  the  pelvis  is  a  matter  of  course.  The  difficulty  will 
consist  not  in  establishing  the  fact  of  a  pelvic  inflammation,  but  in 
determining  its  exact  character  and  extent ;  and  in  distinguishing 
between  pus  conflned  within  the  tube  or  ovary  and  abscess  in  the 
peritoneum  or  cellular  tissue.  To  so  distinguish  is,  however,  of  the 
utmost  importance  from  the  standpoint  of  treatment  ;  for  pus  con- 
fined within  the  tubes  or  ovaries  can  only  be  removed  by  vaginal  or 
abdominal  coeliotomy  ;  while  pus  confined  to  the  peritoneum  or  cel- 
lular tissue  may  perhaps  be  evacuated  without  opening  the  peri- 
toneum. 

The  distinguishing  marks  of  pyosalpinx  and  ovarian  abscess  are 
the  presence  of  a  boggy  or  fiuctuating  circumscribed,  adherent 
tumor,  with  a  sulcus  between  it  and  the  uterus,  into  which  the  fin- 
gers can  be  pressed.     With  pelvic  abscess,  on  the  contrary,  no  dis- 


PELVIC   ABSCESS    IN   WOMEN.  83 

tinct  circumscribed  tumor  can  be  made  out  by  conjoined  manipula- 
tion. The  pelvis  is  simply  filled  witli  a  boggy  or  perhaps  fluctuating 
mass,  the  extent  of  which  cannot  be  exactly  determined. 

The  prognosis  of  pelvic  abscess  in  women  when  left  to  its  own 
course  is  bad.  When  the  pus  is  confined  to  the  tube  or  ovary  the 
patient  is  a  chronic  invalid  ;  and  when  it  escapes  spontaneously 
through  rectum,  vagina,  or  bladder,  the  abscess  cavity  seldom  closes. 
Pus  in  the  pelvic  cellular  tissue  will  usually  find  an  escape  if  the 
life  of  the  patient  be  spared,  but  only  in  few  cases  will  spontaneous 
closure  of  the  abscess  cavity  occur. 

Ti'eatment. — The  first  step  in  the  treatment  of  pelvic  inflammation 
in  w^omen  is  to  limit  its  extent  and  prevent  the  formation  of  pus  if 
possible.  In  every  acute  case  due  to  an  endometritis  whether  gon- 
orrhoeal  or  post-partum,  the  treatment  should  be  commenced  by 
curettage.  The  endometrium  is  the  focus  of  infection,  the  peritoni- 
tis merely  an  attempt  on  the  part  of  nature  to  limit  the  disease.  By 
removing  the  cause,  if  it  be  done  in  time,  we  prevent  further  ravages 
in  the  adnexa  and  pelvis.  In  every  case  of  gonorrhoea,  therefore,  in 
which  the  cavity  of  the  uterus  has  become  involved  ;  and  in  every  case 
of  puerperal  fever  in  which  the  temperature  does  not  rapidly  yield 
to  antiseptic  douching  of  the  interior  of  the  uterus,  the  curette  should 
be  employed  without  dela}^,  provided  pus  has  not  already  formed. 

The  instruments  necessary  for  curettage  are  shown  in  the  follow- 
ing cuts. 

Every  operator  has  his  own  preferences  for  instruments.  The 
uterine  dilator  shown  in  the  cut  has  no  screw  attachment.  The  force 
is  regulated  entirely  by  the  sense  of  resistance  conveyed  to  the  hand  of 
the  operator.  The  catheter  shown  is  perhaps  the  one  most  often  used, 
and  best  adapted  to  secure  a  return  flow.  The  only  objection  to  it 
is  the  care  necessary  to  keep  it  perfectly  clean.  When  the  cervix 
has  been  thoroughly  dilated  a  double  current  instrument  is  not  at 
all  necessary  and  a  simple  glass  female  catheter  will  answer  every 
purpose. 

The  speculum  shown  is  a  modification  of  that  of  Edebohls,  in 
which  the  weight  which  makes  it  self-retaining  is  supplied  by  load- 
ing the  handle. 

With  the  patient  in  the  lithotomy  position  the  vagina  and  vulva 
are  first  scrubbed  with  brush  and  green  soap  and  irrigated  with  bi- 
chloride 1  to  600.  The  speculum  is  then  introduced  and  the  anterior 
lip  of  the  cervix  firmly  seized  with  the  double  tenaculum,  Avhicli  is 


84 


SUKGERY   OF   THE   KECTUM   AND   PELVIS. 


Fig.  46. — Double  Tenaculum. 


Fig.  47. — Uterine  Dilator. 


Fig.  48.— Curette. 


Fig.  49. — Intra-uterine  Catheter. 


Fig.  50.  —Self -retaining  Speculum. 


UlaT  ■="'""'- P  iti  it  I   "-"nfSniTrasi 


Fig.  51. — Uterine  Applicator. 


PKLVIC    ABSCESS    IN    WOMEN.  85 

given  to  an  assistant,  who  holds  the  uterus  well  down.  Introduce  the 
dilator  and  gradually  dilate  the  cervix  till  the  larger  curette  will 
pass  easily.  Trouble  may  be  encountered  at  this  point,  and  it  may 
be  necessary  to  pass  a  small,  straight,  blunt-pointed  bistoury  and 
nick  the  internal  os  before  the  dilator  can  be  introduced. 

With  the  larger  curette  the  endometrium  should  be  removed  com- 
pletely, first  of  all  around  the  internal  os  to  gain  room  for  the  free  use 
of  the  instrument.  The  cavity  of  the  uterus  should  next  be  attacked 
with  some  method  in  order  that  no  parts  may  be  missed.  It  is  well 
first  to  scrape  the  anterior  wall  completely,  then  the  posterior,  then 
each,  lateral.  The  small  instrument  should  then  be  substituted  and 
both  cornua  thoroughly  cleaned.  In  a  thin  and  flabby  organ  great 
safety  may  be  gained  by  keeping  one  finger  on  the  outside  of  the  womb 
for  counter-pressure  against  the  curette  within.  In  this  way  the  instru- 
ment may  be  distinctly  felt  by  the  finger  of  the  other  hand  and  per- 
foration may  be  avoided.  Above  all,  the  operation  should  be  done 
thoroughly  and  no  endometrium  be  left.  There  is  no  danger  from 
mechanical  violence  to  the  womb  if  the  instrument  be  used  till  a  dis- 
tinct sensation  of  grating  against  the  firm  muscular  tissue  of  the 
organ  be  appreciated.  When  the  operation  is  complete  the  womb 
should  be  thoroughly  washed  out  with  warm  saline  solution  and  a 
strip  of  iodoform  gauze  introduced.  It  is  not  at  all  necessary  to  pack 
the  uterus,  a  simple  strip  of  gauze  for  drainage  answering  every 
purpose. 

After  curettage  the  treatment  of  an  acute  pelvic  inflammation  re- 
solves itself  into  rest,  purgation,  and  hot  douches.  To  rest  in  bed 
must  be  joined  absence  of  sexual  intercourse.  By  some  strong 
cathartic  several  watery  evacuations  should  be  secured,  which  will 
not  only  unload  the  large  bowel  of  any  scybalous  masses,  but  which 
will  cause  depletion  by  withdrawal  of  a  certain  amount  of  fluid  from 
the  circulation.  Finally,  hot  vaginal  douches  should  be  given  at 
least  twice  daily,  with  the  patient  lying  upon  her  back  and  the  hips 
elevated  and  shoulders  lowered.  The  temperature  of  the  water 
should  be  only  just  below  the  point  which  will  cause  actual  burn- 
ing— about  100°  F. — and  not  less  than  a  gallon  should  be  used  each 
time.  To  avoid  physical  exertion  on  the  part  of  the  patient,  this 
is  much  better  superintended  by  a  nurse. 

We  come  finally  to  the  surgical  treatment  of  the  results  of  pelvic 
inflammation — the  formation  of  abscesses  in  tubes,  ovaries,  peri- 
toneum or  cellular  tissue  ;  and  here  several  rules  of  treatment  may 


»b  SUEGERT    OF   THE   RECTUM    AND    PELVIS. 

be  enunciated.  After  the  presence  of  pus  has  once  been  diagnos- 
ticated, all  preventive  treatment  may  be  abandoned,  and  surgical 
methods  are  alone  to  be  considered. 

If  the  surgeon  can,  in  any  particular  case,  be  sufficiently  sure  of 
his  diagnosis  to  assert  that  there  is  no  pus  in  either  tubes  or  ovaries, 
but  that  it  is  confined  solely  to  the  peritoneum  or  pelvic  cellular  tis- 
sue, he  may  seek  to  evacuate  it  through  the  vagina,  or  possibly 
through  the  abdominal  wall  extraperitoneally.  The  abscess  sac  may 
be  sufficiently  movable  to  allow  of  its  being  stitched  to  the  abdominal 
wall  before  evacuation  ;  or  the  sac  may  be  opened  and  drained  from 
the  vagina,  and  the  abdominal  exploratory  incision  closed  ;  or  both 
incisions  into  the  sac  may  be  possible,  in  w^hich  case  a  strip  of  gauze 
may  be  passed  through  the  abscess  cavity  from  the  abdominal 
through  the  vaginal  incision. 

In  some  cases  the  patient  will  continue  to  drag  on  a  miserable 
existence  after  the  pus  has  found  an  insufficient  opening  for  itself 
through  either  rectum  or  vagina.  At  longer  or  shorter  intervals 
there  are  attacks  of  acute  pain  lasting  several  days  or  perhaps  weeks, 
and  finall}^  relieved  by  a  flow  of  pus  through  one  or  the  other  cavity. 
It  may  be  possible  in  such  a  case  to  enlarge,  with  dressing-forceps, 
the  opening  already  existing  into  rectum  or  vagina,  and  secure 
sufficient  drainage  to  bring  about  a  cure.  Abdominal  section  is  more 
dangerous  in  these  than  in  the  cases  where  no  sinus  communicates 
with  the  external  world  on  account  of  the  very  existence  of  the 
sinus.  After  ablation  of  the  sac,  the  sinus  becomes  a  direct  point 
for  entrance  of  septic  matter,  which  must  be  closed  if  possible,  after 
thorough  curettage  and  cauterization,  by  suturing  from  within  the 
abdomen. 

While  until  within  a  few  years  it  was  always  taught  that  the 
only  way  of  removing  pus-tubes  and  ovaries  was  by  abdominal  sec- 
tion, more  recent  work  has  shown  the  great  advantages  of  vaginal 
over  abdominal  coeliotomy  in  many  of  these  pus  cases.  Just  as  it 
was  formerly  advised  to  open  an  extra-peritoneal  abscess  through 
the  nearest  point — the  vagina  if  possible,  and  allow  of  drainage  in 
the  most  dependent  part  of  the  sac,  it  is  now  known  that  all  collec- 
tions of  pus  in  the  pelvis,  extra-  or  intra-peritoneal,  tubal  or  ovarian, 
can  be  evacuated  by  this  route,  and  many  of  them  better  by  this 
than  any  other.  The  most  marked  exception,  perhaps,  is  in  the 
class  of  abscesses  which  have  already  distinctly  pointed  upward 
toward  the  abdominal  wall. 


PELVIC    ABSCESS    IN    WOMEN. 


87 


The  pelvis  may  be  opened  through  the  vagina  either  in  front  or 
behind  the  uterus  ;  tubes  and  ovaries  brought  down  into  full  view, 
and  returned  or  removed  as  their  condition  seems  to  demand  ;  pus 
cavities  anywhere  thoroughly  evacuated  ;  and  drainage  established 
with  much  less  risk  of  causing  septic  peritonitis  than  where  pus-sacs 
are  ruptured  in  an  attempt  to  enucleate  them  through  an  abdominal 


-^ 


■^l_0  _G^  E  RM  O  L  D 


Fig.  53. 


incision,  the  pus  necessarily  coming  in  contact  with  the  pelvic  and 
abdominal  contents.  Moreover,  the  fact  that  this  can  be  done  with- 
out inflicting  an  unsightly  scar  is  by  no  means  a  trivial  one. 

In  many  of  these  cases  it  is  best  to  remove  the  uterus  with  the 
purulent  collections.  Especially  is  this  true  where  both  adnexa  are 
purulent,  and  where  pus-cavities  have  already  communicated  with 
rectum  or  vagina.  The  uterus,  even  after  both  adnexa  have  been  re- 
moved, may  still  keep  up  a  constant  trouble,  which  can  only  be  cured 
by  a  secondary  operation  of  hysterectomy.    Its  removal  through  the 


Fig.  58. — Vaginal  Retractors. 


vagina  when  this  has  been  opened  to  reach  pus  in  the  pelvis  adds 
nothing  to  the  gravity  of  the  operation,  in  fact  allows  of  much  better 
drainage,  and  gives  more  room  for  the  operator. 

There  is  one  decided  contra-indication  to  these  operations  through 
the  vagina — a  deep  and  narrow  pelvis.  Where  the  pelvis  is  broad 
and  shallow  there  is  abundance  of  room  for  manipulation.     In  other 


88 


SURGERY   OF   THE   RECTUM   AND   PELVIS. 


Fig.  54. — Cleveland  Ligature  Carrier. 


Fig.  55. — Heavy  Tenaculum. 


INTESTINE 


Fig.  56. — Hagedorn  Needles. 


Fig.  57. — Needle-holder. 


PELVIC    ABSCESS    IN    WOMEN.  89 

cases  it  may  be  better  to  operate  from  above  or  to  gain  additional 
room  by  lateral  incisions  in  the  vulva. 

Yaglnal  Hysterectomy. — There  are  two  different  methods  of 
operating  ;  one  in  which  the  broad  ligaments  are  secured  by  clamps, 
the  other  in  which  ligatures  are  used  in  place  of  clamps.  It'  clamps 
are  to  be  used,  at  least  two  dozen  should  be  at  hand  of  different 
sizes.  Jacobs'  clamp  is  shown  in  Fig.  52.  It  is  a  large  heavy  instru- 
ment, and  can  well  be  supplemented  by  smaller  and  more  delicate 
ones. 

The  other  instruments  necessary  are  self-retaining  speculum,  a  set 
of  vaginal  retractors  with  two  handles  (Fig.  53),  long  strong  scissors, 
the  Cleveland  ligature-carrier  (Fig.  54),  strong  double  tenaculum 
(Fig.  55),  full  curved  Hagedorn  needles,  large  and  medium  (Fig.  56), 
needle-holder  (Fig.  57),  and  catgut  in  three  sizes — heavy,  medium, 
and  fine. 

With  the  patient  in  the  dorsal  position  and  the  legs  in  upright 
supporters,  scrub  the  vagina  and  labia  with  green  soap,  curette  the 
cervical  canal,  and  plug  the  womb  with  iodoform  gauze  ;  irrigate 
thoroughly  with  1  to  500  bichloride,  and  wash  finally  with  sterile 
water.  Have  the  irrigator  filled  with  an  ample  supply  of  sterile 
water.  The  self-retaining  speculum  will  alone  often  give  sufficient 
room  for  all  manipulation,  but  the  other  retractors  may  be  used  on 
the  sides  and  anterior  wall  of  the  vagina,  as  necessary. 

Seize  the  cervix  through  both  lips  with  a  strong  tenaculum,  draw 
it  down  and  make  a  transverse  incision  through  Douglas'  pouch 
into  the  peritoneal  cavity.  Should  there  be  free  bleeding  from  this 
incision  it  is  well  to  whip  over  the  posterior  cut  edge  with  a  continu- 
ous suture  of  fine  catgut,  and  to  include  in  this  suturizing  the  free 
edge  of  the  peritoneum. 

Through  this  incision  alone  many  pus  sacs  may  be  evacuated, 
and  if  tubes  and  ovaries  be  found  free  from  pus  the  operation  need 
proceed  no  farther  ;  the  pus-cavity  being  simply  drained  by  pack- 
ing with  gauze. 

A  pus-tube  or  ovary  may  also  be  brought  down  and  removed 
through  this  incision  without  rupture,  and  if  there  has  been  no  soil- 
ing of  the  peritoneum  the  incision  may  be  closed.  Should  it  be 
necessary,  however,  to  completely  remove  the  uterus  and  adnexa,  the 
next  step  is  to  make  an  incision  around  the  anterior  lip  of  the  cervix 
low  enough  down  to  avoid  the  reflection  of  the  bladder,  and  connect 
the  ends  of  this  incision  with  the  former  one.     With  the  finger  and 


90 


SURGERY    OF   THE    RECTU:M   AND    PELVIS. 


handle  of  the  scalpel  dissect  up  the  bladder  from  the  uterus  until  the 
peritoneum  is  again  opened  in  front,  and  if  there  is  bleeding  from  the 
cut  edge  of  the  vagina  continue  the  overhand  suture  of  the  cut  edge 
to  the  peritoneum,  as  on  the  posterior  lip  of  the  incision. 

The  ligation  of  the  broad  ligaments  in  sections  may  now  be  car- 
ried out.  For  this  purpose  either  the  ligature-carrier  or  a  strong 
curved  needle  may  be  used,  and  heavy  catgut  is  the  best  material. 


Fig.  58.— Opening  Douglas'  Pouch  in  Vaginal  Hysterectomy. 

The  first  ligature  on  each  side  should  include  the  uterine  arteries 
and  avoid  the  ureters  (Fig.  59).  Both  ends  of  the  ligature  should  be 
cut  short,  and  the  tissue  between  the  ligature  and  the  uterus  cut 
through  with  scissors  as  close  to  the  uterus  as  possible.  Before 
dividing  the  tissue  it  is  well  to  seize  the  tissue  outside  the  ligature 
with  a  small  clamp.  In  case  the  uterine  artery  be  not  firmly  secured 
the  bleeding  point  in  the  stump  is  then  in  plain  view  and  under  full 
control,  and  a  second  ligature  may  easily  be  passed  by  transfixing 
the  stump  with  an  armed  needle.  The  ligation  of  the  lower  segments 
of  the  broad  ligaments  and  their  division  allows  the  uterus  to  be 


PELVIC   ABSCESS   IN   WOMEN. 


91 


brought  still  farther  down,  and  a  second  ligature  may  be  passed  on 
each  side  and  another  segment  divided  again  close  to  the  uterus. 
Three  ligatures  on  each  side  will  usually  be  sufficient  (it  may  be  done 
with  two)  and  the  last  should  pass  outside  of  the  ovaries  so  that  they 
will  be  left  attached  to  the  uterus  and  come  away  with  it. 

After  opening  the  peritoneum  both  above  and  below,  it  is  easily 
possible  by  dissecting  well  into  the  uterine  tissue  on  each  side  to 


Fig.  59. — Vaginal  Hysterectomy  with  Ligatures. 


avoid  the  uterine  arteries  entirely,  thus  leaving  only  the  upper  part 
of  the  broad  ligament  to  be  ligatured  or  clamped  and  dispensing  with 
the  first  ligature  around  the  uterine  artery  on  each  side. 

In  some  cases  after  ligating  the  uterine  arteries  on  each  side,  the 
uterus  may  easily  be  rotated  upon  itself  and  the  fundus  pulled  down 
into  the  wound  while  the  cervix  is  released.  This  causes  a  half  turn 
in  the  broad  ligaments  and  facilitates  ligating  the  remaining  portions, 
and  is  thus  of  advantage  when  not  too  much  time  or  force  is  required 
to  effect  the  manoeuvre. 

The  operation  with  clamps  differs  in  no  way  from  that  with  the 


92  SUKGERY    OF   THE   EECTUM   AND   PELVIS. 

ligature,  except  that  each  section  of  the  broad  ligament  is  clamped 
instead  of  ligated  before  division ;  bat  the  completion  of  the  opera- 
tion is  decidedly  modified.  The  clamps  should  be  left  in  situ  thirty- 
six  hours,  the  wound  and  vagina  around  them  packed  with  iodoform 
gauze,  and  the  handles  covered  with  aseptic  dressing  where  they  pro- 
trude between  the  thighs.     Their  presence  adds  considerably  to  the 


Fig.  60. — Vaginal  Hysterectomy  with  Clamps. 

discomfort  of  the  patient  while  they  remain,  and  there  is  always 
some  risk  that  one  may  become  loosened  and  bleeding  result.  Their 
removal  after  thirty-six  hours  is  also  a  cause  of  nervous  irritation  to 
the  sufferer. 

With  the  ligatures,  on  the  other  hand,  if  the  operation  has  been 
aseptic,  the  wound  in  the  vagina  may  be  completely  closed  by  sut- 
ures after  the  stumps  have  been  drawn  down  into  the  vagina  and 
thus  placed  outside  of  the  peritoneal  cavity  (Fig.  61),  or  the  wounds 
in  the  broad  ligaments  maybe  closed  by  continuous  suture,  the  lower 


PELVIC    ABSCESS    IN    WOMEN. 


93 


stumps  on  each  side   drawn  through   the  vaginal  wound  and  this 
also  sutured. 

But  unless  the  operation  has  been  aseptic,  that  is,  unless  the  pus 
has  been  removed  in  its  ovarian  or  tubal  sac  without  rupture  and 


Fig.  61. — Closing  the  Vagina  after  Hysterectomy. 

soiling  of  the  wound,  no  attempt  to  close  the  vaginal  incision  should 
be  made.  It  should  on  the  contrary  be  stuffed  with  bichloride  gauze 
and  left  open  for  drainage. 


94 


SURGERY   OF   THE   RECTUM   AND   PELVIS. 


In  operating  for  extraperitoneal  abscesses  or  those  sacculated 
within  the  peritoneum  at  some  stage  in  this  operation  the  wound 
will  be  deluged  with  pus.  It  is  just  here  that  the  great  advantages  of 
this  procedure  become  manifest,  for  under  a  steady  irrigation  the  pus 
escapes  through  the  vaginal  incision  without  fouling  the  abdomen. 
The  operator  continues  steadily  with  his  work  of  breaking  down 
adhesions  and  liberating  pus,  until  the  broad  ligaments  are  secured 


Fig.  63. 


and  the  adnexa  removed,  when  the  pelvis  and  vagina  are  packed 
with  gauze. 

Should  it  be  deemed  best  in  cases  of  tubal  or  ovarian  abscess  to 
operate  through  an  abdominal  incision,  the  greatest  care  must  be 
taken  to  avoid  rupturing  the  pus-sacs  and  emptying  their  contents 
into  the  peritoneal  cavity.  This  will,  however,  often  be  unavoidable, 
and  every  precaution  must  be  used  to  prevent  the  contact  of  the  pus 
with  the  adjacent  parts  by  careful  use  of  flat  sponges.  If  the  abdom- 
inal incision  is  closed  after  such  an  operation  drainage  should  pre- 
viously be  made  through  the  vagina,  and  the  pelvis  should  be  care- 
fully wiped  free  from  all  blood  and  pus,  but  not  ii-rigated.     When 


PELVIC   ABSCESS   IN    WOMEN. 


95 


Fig.  63. 


Fig.  64.— Abdominal  Hyscexeotomy  with  Drainaf^e. 


96 


SURGERY   OF   THE   RECTUM    AND   PELVIS. 


both  adnexa  are  diseased  it  will  often  be  best  also  to  remove  the 
uterus,, and  this  may  be  done  either  by  total  or  supra-vaginal  excis- 
ion. In  the  supra-vaginal  amputation  the  stump  of  the  cervix  is  left, 
and  the  vagina  is  not  opened.  The  only  advantage  of  this  operation 
is  the  saving  of  time  and  the  avoidance  of  the  slight  bleeding  always 
attendant  upon  cutting  through  the  vagina.  The  cervix  should 
always  be  curetted  before  such  an  operation  to  avoid  infection  of 
the  wound,  and  after  the  amputation  it  may  either  be  closed  by  a 
continuous  suture  as  in  Fig.  62,  or  a  gauze  drain  may  be  introduced 


Fig.  65. — Abdominal  Hysterectomy  with  Closure  of  Vagina  and  Peritoneal  Incision. 


as  in  Fig.  63,  depending  upon  whether  the  operation  has,  or  has  not 
been  aseptic,  as  in  Fig.  63.  Another  argument  in  favor  of  the  supra- 
vaginal operation  is  that  by  not  removing  the  stump  of  the  cervix  an 
additional  safeguard  remains  against  vaginal  hernia — an  argument, 
however,  to  which  but  little  weight  is  attached  by  most  operators. 

In  either  the  complete  or  the  supra-vaginal  operation  I  much  prefer 
the  technique  described  and  practised  by  Edebohls,  in  which  he  first 
ligatures  the  uterine  arteries  and  subsequently  the  remainder  of  the 
broad  ligaments  instead  of  mce  versa.  Having  removed  the  entire 
organ  and  checked  all  hemorrhage  the  incision  in  the  vagina  and 
peritoneum  may  either  be  packed  with  gauze  to  allow  of  drainage, 


PELAGIC   ABSCESS   IN   WOMEIST.  97 

as  shown  in  Fig.  64,  or  the  complete  closure  of  the  wound  may  be 
carried  out  as  shown  in  Fig.  65. 

In  cases  of  post-partum  sepsis,  with  high  temperature  and  pelvic 
phlegmon,  it  will  generally  be  safer  to  do  a  partial  operation  and 
evacuate  the  pus  through  a  vaginal  incision  at  first  than  to  attempt 
complete  removal  of  the  uterus  and  adnexa  with  the  patient  in  such 
a  condition.  Should  the  patient  survive  the  attack  and  subsequent 
more  radical  treatment  be  necessary  it  may  then  be  carried  out  with 
much  better  prospect  of  success. 


CHAPTER   YIII. 

FISTULA. 

A  FISTULA  which  is  not  due  to  ulceration  and  perforation  of  the 
rectal  wall  from  within  is  the  result  of  a  previous  abscess,  and, 
therefore,  in  enumerating  the  causes  of  abscess  those  of  fistulge  have 
also  been  given.  Like  the  abscesses  from  which  they  arise,  they  may 
well  be  divided  into  superficial  and  deep  ;  or  into  those  of  the  anus, 
which  are  subcutaneous  and  involve  at  the  most  only  a  few  fibres  of 
the  external  sphincter,  and  those  of  the  rectum  and  pelvis,  which 
open  into  the  bowel  at  a  higher  point,  or  perhaps  on  the  surface  at  a 


Fig.  66.— Varieties  of  Fistula. 


considerable  distance  from  the  rectum.  Both  the  superficial  and 
deep  may  also  be  divided  into  the  complete,  or  those  which  open  both 
on  the  skin  and  into  the  bowel ;  the  external,  which  open  only  on 
the  skin  ;  and  the  internal,  which  have  an  opening  only  within  tlie 
bowel  (Fig.  66). 

Superficial  FistulcB. — On  account  of  the  special  laxity  of  the 
submucous  connective  tissue  in  this  region,  abscesses  show  little  ten- 
dency to  spontaneous  closure,  and  fistula  is  the  common  result  when 
left  to  their  own  course.  In  the  subcutaneous  fistula  the  external 
orifice  may  be  at  some  distance  from  the  anus  or  in  the  radiating 


FISTULA. 


99 


folds.  The  presence  of  more  than  one  external  orifice  is  rare  in  sub- 
cutaneous fistulse  ;  and  an  internal  opening  will  be  found  in  most 
if  properly  searched  for.  The  best  way  to  settle  the  question  of  the 
presence  or  absence  of  an  internal  opening  in  any  doubtful  case  is  by 
injecting  milk  through  the  external  orifice.  In  the  vast  majority  of 
cases  the  milk  will  be  found  in  the  rectum,  and  the  internal  orifice 
will  be  found  just  within  the  external  sphincter.  In  some  the 
opening   will   be   found   in  tlie   radiating   folds   entirely  below  the 


Figs.  67  and  68. — Fistulse  with  Double  Tracks. 

fibres  of  the  sphincter,  and  in  others  it  may  be  much  higher  up  the 
bowel. 

The  internal  orifice  does  not  in  all  cases  mark  the  superior  limit 
of  the  fistulous  track.  This  may  run  several  inches  up  the  bowel 
under  the  mucous  membrane  when  the  internal  orifice  is  just  within 
the  external  sphincter  (Figs.  67  and  68). 

The  track  of  a  fistula  is  sometimes  straight,  extending  directly 
from  one  orifice  to  the  other  ;  in  other  cases  a  track,  properly  speak- 
ing, does  not  exist,  and  both  orifices  open  directly  into  the  original 
abscess  cavity.  If  the  external  orifice  be  very  small,  the  cavity  may 
at  any  time  become  distended  with  pus  and  give  rise  to  all  the  symp- 
toms of  a  fresh  abscess  till  the  pus  finds  an  exit  through  either  the 
old  opening  or  a  new  one.  The  track  is  lined  with  lardaceous  tissue, 
the  result  of  chronic  inflammation,  and  in  this  ma}"  be  found  numer- 
ous blood-vessels  of  new  formation.  This  tissue,  by  preventing  all 
contact  with  the  walls,  necessarily  prevents  healing.  On  the  other 
hand,  the  track  is  sometimes  lined  with  healthy  granulations  which 


lOU  SUKGERY    OF   THE    EECTUM   AIN^D    PELVIS. 

are  capable  of  being  formed  into  new  tissue,  and  for  this  reason  a 
fistula  will  sometimes,  though  very  rarely,  heal  spontaneously. 

The  symptoms  caused  by  this  class  of  fistulse  vary  greatly.  At 
first  they  are  those  of  the  abscess  in  which  they  originate.  After 
that  the  one  great  symptom  is  the  incessant  discharge,  sometimes 
slight,  at  others  abundant ;  sometimes  purulent,  at  others  serous  ; 
always  fetid  ;  sometimes  containing  faeces  and  gas.  Besides  the 
discharge  there  may  be  no  symptoms  at  all,  or  there  may  be  more  or 
less  uneasiness  in  the  part,  and  pain  on  defecation,  with  the  consti- 
pation which  arises  from  the  fear  of  a  passage,  and  the  symptoms  to 
which  it  gives  rise.  Such  a  state  of  affairs  may  exist  for  many  years 
without  aggravation  or  causing  the  patient  to  seek  relief. 

Deep  FistulcE. — Fistulse  resulting  from  ischio-rectal  abscesses 
differ  greatly  in  their  extent  and  gravity  from  those  last  described. 
In  them  the  track  is  large,  and  often  double  or  branching,  and  the 
external  opening  may  be  far  away  from  the  anus.  The  whole  per- 
ineum and  gluteal  region  will  sometimes  be  found  brawny  and  in- 
durated, and  twenty  or  thirty  openings  may  be  counted,  with  the 
scars  of  others  which  have  closed. 

The  fistulse  resulting  from  deep  pelvic  abscesses  are  of  many 
different  varieties,  all  of  them  severe.  The  external  opening  may  be 
far  away  from  the  anus,  and  there  may  be  several  tracks  and  open- 
ings which  may  branch  off  from  each  other,  or  all  may  communicate 
with  a  common  abscess  cavity  in  the  pelvis.  When  an  internal 
opening  alone  exists  it  may  be  in  the  rectum,  vagina,  urethra,  blad- 
der, or  any  part  of  the  alimentary  canal. 

The  track  in  some  of  these  cases  lias  been  known  to  take  a  re- 
markably irregular  course.  Sir  A.  Cooper  mentions  an  autopsy 
where  a  fistula  opened  in  the  groin,  followed  the  course  of  the  sper- 
matic cord,  and  ended  in  what  seemed  like  an  ordinary  fistula  in 
ano  ;  and  cases  in  which  the  pus  has  burrowed  under  the  gluteal 
muscles  and  finally  opened  in  the  thigh,  loin,  or  even  nearly  at  the 
popliteal  space,  are  not  uncommon. 

Blind  Internal  Fistula. — Fistulse  about  the  anus  with  internal 
openings  alone  have  a  somewhat  special  pathology.  When  caused 
by  an  abscess  it  is  generally  by  one  of  the  deep  variety  which  has 
opened  into  the  rectum  high  up  and  continues  to  discharge  in  this 
way.  The  abscess  causing  such  a  fistula  may,  however,  be  a  small 
submucous  one  or  a  large  subcutaneous  one.  There  is  another  and 
perhaps  more  common  class  of  internal  fistulffi  in  which  the  opening 


FISTULA.  *  101 

is  not  the  result  of  the  breaking  of  an  abscess,  but  is  first  formed  by 
ulceration,  and  the  track  is  a  secondary  consequence. 

A  circumscribed  ulcer  which  perforates  the  mucous  membrane 
and  results  in  internal  fistula  may  be  due  to  several  causes  :  to  rupt- 
ure of  an  inflamed  internal  hemorrhoid  ;  to  the  application  of  strong 
acids  to  hemorrhoids  ;  to  operations  upon  the  rectum  ;  and  espe- 
cially to  tubercular  ulceration. 

Such  a  condition  is  a  very  j)ainful  one.  The  opening,  which  may 
be  large  enough  to  show  a  distinct  loss  of  substance  to  the  touch, 


/ 


Fig.  69.— Tubercular  Fistula. 

catches  and  retains  particles  of  faeces,  causing  a  burning  pain  which 
may  last  many  hours  after  defecation.  As  a  result  of  the  opening  an 
abscess  forms  after  a  time,  with  the  usual  sjmiptoms,  the  induration 
of  which  may  be  felt  externally.  When  the  abscess  is  small  and  the 
induration  not  extensive,  a  speculum  examination  may  reveal  the 
ulcer ;  but  the  fistulous  track  and  abscess  may  escape — a  mistake 
which  will  render  all  treatment  directed  toward  the  cure  of  the  ulcer 
of  no  avail.  There  may  indeed  be  several  ulcers,  only  one  of  which 
has  a  fistula  connected  with  it. 

Fistulse  of  this  variety  differ  very  much  in  character  ;  but  taking 
them  as  a  class,  I  know  of  no  branch  of  rectal  troubles  so  apt  to  lead 
to  errors  in  diagnosis  or  mistakes  in  practice.     Some  of  them  are 


102  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

perfectly  apparent  by  even  a  cursory  examination.  The  internal 
opening  may  be  so  large  that  the  finger  enters  an  abscess  cavity  on 
introducing  it  into  the  anus,  while  the  skin  of  the  ischio-rectal  fossa 
is  reddened  and  thinned  and  the  pus  is  about  to  break  through  the 
surface.  This  condition  is  most  frequently  seen  as  a  result  of  tuber- 
cular deposit  (Fig.  69).  On  the  other  hand,  the  internal  orifice  may 
be  so  small  as  scarcely  to  admit  the  finest  probe,  there  may  be  only 
a  small  straight  track  and  no  abscess  cavity,  and  the  condition  may 
require  the  most  thorough  and  careful  examination  under  ether  for 
its  detection.  The  patient  may  complain  only  of  pain  strongly  re- 
sembling that  of  fissure  or  simple  neuralgia  of  the  rectum,  and  the 
purulent  discharge  may  be  so  slight  as  to  escape  notice. 

The  mere  diagnosis  of  the  existence  of  a  fistula,  except  in  the 
blind  internal  variety,  is  usually  attended  by  little  difliculty.  The 
examination  of  the  extent  and  variety  of  a  fistulous  track,  however, 
is  a  matter  requiring  delicac}^  and  skill.  The  best  position  is  on  the 
affected  side,  with  limbs  flexed  on  the  abdomen.  The  examiner 
should  be  provided  with  probes  of  every  variety,  from  the  small  ones 
made  of  pure  silver  to  the  soft  metal  uterine  sound  ;  and  it  is  better 
not  to  begin  the  examination  with  any  preconceived  idea  as  to  the 
direction  of  the  track,  for  this  is  exactly  what  the  probe  is  to  deter- 
mine. The  instrument  should  be  allowed  to  follow  the  track,  and 
not  be  forced  toward  the  gut,  or  indeed  in  any  direction.  After  it 
has  gone  as  far  as  it  will,  the  index  finger  of  the  other  hand  may  be 
introduced  into  the  rectum  and  try  to  detect  the  end  of  the  probe. 
Sometimes  it  will  be  found  free  in  the  rectum ;  sometimes  it  can 
be  felt  covered  only  by  mucous  membrane,  but  no  internal  opening 
can  be  discovered  ;  and  again,  rather  to  the  surprise  of  the  opera- 
tor, it  may  not  be  felt  at  all,  having  passed  directly  away  from  the 
bowel. 

In  the  diagnosis  of  the  blind  internal  variety  there  is  a  chance  for 
much  skill.  I  have  known  a  small  fistula  of  this  kind  to  escape  de- 
tection by  a  dozen  different  men,  and  to  be  treated  for  almost  every 
other  form  of  rectal  affection.  The  absence  of  any  external  orifice 
misleads  the  superficial  examiner  at  the  beginning,  and  the  failure  to 
make  a  thorough  examination  completes  the  error. 

There  are  two  signs  of  this  condition  which  will  in  every  case  lead 
to  a  correct  diagnosis.  The  one  is  the  discovery  of  the  internal  orifice, 
the  other  and  more  valuable  is  the  induration  which  invariably  at- 
tends a  track  of  any  size.     The  whole  course  of  a  fistula  can  often  be 


FISTULA.  103 

marked   out   distinctly  by   the  detection  of   a  whip-cord   hardness 
running  around  the  anus  under  the  skin. 

Treatment. — A  fistula  may  heal  spontaneously  or  after  a  very 
slight  excitement  to  reparative  action,  such  as  the  mere  passage  of  a 
probe  in  making  an  examination.  It  has  been  mentioned  that  the 
track  is  sometimes  lined  with  healthy  granulations,  and  that  these 
may  result  in  new  tissue  which  shall  close  it.  I  have  the  notes  of 
one  such  case  where  a  fistula  of  several  years'  standing  closed  spon- 
taneously without  even  the  passage  of  a  probe  to  excite  it  to  repara- 
tive action,  but  I  have  never  seen  more  than  one. 

Setting  aside  these  cases,  we  are  at  once  brought  to  the  question, 
which  will  often  be  asked  by  the  patient,  and  which  the  surgeon  may 
not  always  be  able  to  answer  to  his  own  satisfaction — whether  it  is 
always  best  or  even  safe  to  try  and  cure  a  fistula.  In  certain  cases 
of  Bright' s  disease,  cancer,  cardiac  and  hepatic  affections,  etc.,  all 
surgical  interference  maj''  be  contra-indicated  ;  but  the  question  is 
most  apt  to  arise  in  tubercular  patients.  My  own  practice  has  al- 
ways been  to  operate  upon  tubercular  cases  as  upon  others  when 
there  was  any  hope  of  effecting  a  cure  of  the  local  affection.  There 
are  several  rules  which  should  be  carefully  regarded  in  this  class  of 
cases,  however.  No  cautious  practitioner  would  think  of  operating 
either  in  a  very  advanced,  or  rapidly  advancing,  general  tuberculosis. 
Cough,  when  violent  and  frequent,  is  also  a  decided  contra-indica- 
tion,  interfering,  as  it  does  very  certainly,  with  the  healing  of  the 
wound.  Moreover,  in  every  case  where  there  is  any  suspicion  of 
tuberculosis,  the  whole  extent  of  the  fistula  should  be  thoroughly 
curetted  or  destroyed  with  the  Paquelin  cautery.  There  is  no  doubt 
that  a  tubercular  fistula  may  be  the  first  symptom  of  what  will  later 
develop  into  a  general  infection,  and  that  its  complete  destruction 
may  prevent  a  general  deposit,  as  may  happen  in  tubercular  deposit 
in  the  testicle. 

The  after-treatment  of  a  tubercular  patient  is  always  a  matter  of 
great  importance,  for  these  incisions  may  refuse  to  heal  even  when 
they  look  perfectly  healthy.  The  patient  should  not  be  confined  to 
bed  any  longer  than  is  absolutely  necessary,  and  if  his  general  health 
is  better  in  the  open  air  he  should  be  encouraged  to  go  out  as  soon  as 
the  wound  will  permit,  even  though  rectal  wounds  do  heal  better  in 
the  recumbent  posture.  But  here  the  general  health  must  take  prece- 
dence. The  diet  should  be  the  most  nourishing  possible,  change 
of  air  should  be  sought,  tonics  of  all  varieties  should  be  given,  and 


104  SUEGERY    OF   THE   EECTUM    AND   PELVIS. 

the  local  treatment  should  be  gently  stimulating.  It  is  often  useless, 
however,  to  change  local  dressings  and  to  worry  over  the  wound.  If 
the  cut  shows  no  tendency  to  heal,  and  there  be  no  sinus  to  account 
for  the  sluggishness,  it  is  the  patient  himself  who  must  be  cared  for, 
and  the  particular  form  of  dressing  will  make  little  difference. 

In  cases  of  fistula  in  tubercular  patients,  or  those  in  feeble  general 
health  from  any  other  cause,  the  sphincters  should  be  interfered  with 
as  little  as  possible.  They  are  apt  to  be  weak  at  the  best,  and  the 
less  cutting  of  them  that  is  done  the  better. 

Having  decided,  then,  to  try  and  cure  the  fistula,  many  ways  are 
open.  In  certain  selected  cases  a  cure  may  be  effected  by  stimulating 
the  track  and  allowing  a  free  discharge  of  pus  without  any  cutting 
operation.  For  this  purpose  dilatation  of  the  external  orifice  by  sea- 
tangle  tents,  the  introduction  of  drainage-tubes,  injections  of  tur- 
pentine and  iodine,  and  applications  of  nitrate  of  silver  and  caustic 
potash  have  all  been  successful.  Treatment  by  any  of  these  methods 
requires  time  and  patience,  and  the  result  cannot  be  looked  upon  as 
at  all  certain  ;  and  yet  all  of  them  hold  out  a  certain  slight  prospect 
of  success,  if  the  patient  be  in  condition  to  submit  to  their  trial. 

In  cases  of  recent  abscess  of  the  ischio-rectal  fossa  where  the  pus 
has  broken  out  on  the  skin  but  no  internal  opening  has  yet  formed, 
the  chances  of  success  by  this  method  are  very  good.  The  patients 
should  be  kept  in  bed  and  the  outer  opening  be  enlarged  to  allow  of 
free  escape  of  matter.  Then,  by  free  drainage  and  injections  of  bi- 
chloride 1  to  2,000,  the  abscess  cavity  is  very  likely  to  heal.  In  older 
cases,  where  a  true  pyogenic  membrane  has  formed,  the  applications 
must  be  much  stronger,  and  in  these  turpentine,  iodine,  or  caustic 
potash  will  succeed  much  better. 

When  it  has  been  decided  to  lay  the  fistula  open  into  the  gut, 
there  is  but  one  method  which  can  be  thoroughly  recommended,  and 
that  is  the  knife.  The  elastic  ligature  and  ecraseur  need  not  be  con- 
sidered except  in  cases  where  the  patient  is  too  timid  to  submit  to 
the  knife.  The  silk  ligature  is  unsurgical  and  the  elastic  ligature 
and  galvano  cautery  wire  possess  no  advantages  to  an  operator  who 
does  not  fear  hemorrhage,  and  who  acts  on  the  surgical  principle  that 
what  vessels  he  may  cut  he  can  also  secure. 

The  operation  for  fistula  by  incision  may  be  greatly  facilitated  by 
the  observance  of  several  minor  details.     In  this,  as  in  other  opera- 
tions on  the  part,  the  bowels  should  be  thoroughly  emptied  on  the/ 
previous  day.     In  all  cases  in  which  the  track  is  of  any  considerable 


FISTULA.  105 

deptli,  or  in  which,  on  account  of  sensitiveness  of  the  patient,  the 
surgeon  has  not  been  able  to  assure  himself  of  the  exact  extent  of 
the  disease  and  the  absence  of  any  side  tracks  or  diverticula,  ether 
should  be  given  and  the  anus  gently  and  completely  dilated  before 
the  operation.  It  is  only  in  the  simplest  cases  that  the  incision  may 
be  made  without  ether,  and  then  the  best  chance  of  a  thoroughly 
satisfactory  exploration  is  missed,  and  the  way  is  opened  for  an  in- 
complete and  therefore  unsuccessful  operation. 

For  deep  tracks,  if  a  knife  is  used,  it  should  be  strongly  made,  for 
it  is  not  a  very  difficult  matter  to  break  an  ordinary  scalpel  in  a  deep 
fistula.  A  heavy  steel  director  may  also  be  snapped  in  an  attempt 
to  bring  the  end  out  of  the  anus  preparatory  to  making  the  incision  ; 
and  should  the  internal  orifice  be  high  up,  and  the  external  at  some 
distance  from  the  anus,  so  that  the  amount  of  tissue  to  be  divided  is 
large,  it  is  often  better  to  discard  the  knife  and  use  a  pair  of  strong 
scissors. 

When  no  internal  orifice  can  be  found,  but  the  mucous  membrane 
feels  undermined  and  the  probe  can  be  felt  by  the  finger  in  the  rectum, 
separated  only  by  a  thin  layer  of  mucous  membrane,  it  is  a  good 
plan  to  force  an  internal  opening  and  treat  the  fistula  as  though  it 
were  complete.  When  there  are  two  internal  openings,  both  should 
be  included  in  one  incision.  When,  after  the  incision,  the  diseased 
integument  is  found  to  overlap  the  cut  and  hang  into  it,  it  should  be 
cut  away  ;  and  in  old  tracks  the  healing  may  be  hastened  many  days 
by  thoroughly  scraping  out  the  lardaceous  wall  with  the  handle  of 
the  scalpel,  or  even  scarifying  it  in  several  places,  so  that  a  healthy 
reparative  action  may  be  set  up. 

Where  the  fistulous  tracks  exist  in  great  numbers,  two  or  three 
operations  may  be  advisable  at  intervals,  rather  than  to  attempt  to 
do  all  at  one  sitting,  lest  the  patient's  reparative  powers  should  be 
unequal  to  the  task  thrown  upon  them.  In  such  cases  there  will 
often  be  found  two  or  three  tracks  which  may  be  considered  as 
primary,  into  which  the  others  run  ;  and  each  of  these,  with  its 
branches,  may  be  dealt  with  at  a  separate  operation.  Many  of  the 
tracks  will  be  found  to  run  away  from  the  bowel  under  the  skin  of 
the  buttock  or  toward  the  scrotum,  and  these  may  be  induced  to  heal 
by  laying  them  open,  without  interfering  with  the  sphincters.  It  will 
sometimes  be  necessary  to  divide  the  sphincter  several  times,  how- 
ever, before  the  cure  can  be  completed,  and  a  certain  degree  of  incon- 
tinence may  be  expected  as  a  result. 


106  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

In  the  matter  of  dressings  after  the  incision  much  skill  may  be 
displayed.  Immediately  after  the  operation  a  dressing  of  plain  or 
iodoform  gauze  should  be  introduced  and  kept  in  place  by  a  T-band- 
age.  To  save  the  patient  as  much  pain  and  annoyance  as  possible, 
this  should  not  be  removed  till  after  two  or  three  days,  when  it  will 
have  become  soft  and  loose  from  the  discharge.  Subsequent  dress- 
ings may  be  of  the  same  material  and  should  be  changed  daily.  The 
wound  should  not  be  tightly  packed  with  lint.  It  will  heal  from  the 
bottom  if  its  surfaces  are  kept  apart  or  separated  daily  by  the  finger 
of  the  surgeon.  Care  is  always  necessary  to  prevent  an  immediate 
union  of  the  cutaneous  edges  of  the  incision.  In  my  own  practice  I 
seldom  use  any  dressing  at  all  after  the  first,  but  merely  introduce  a 
finger  into  the  wound  two  or  three  times  a  week  to  secure  healing 
from  the  bottom,  and  apply  sufficient  gauze  to  the  surface  to  catch 
the  discharge. 

Healing  may  be  indefinitely  delayed  by  too  frequent  dressings,  or 
by  stuffing  the  wound  tightly  with  the  intention  of  forcing  it  to  heal 
from  the  bottom.  Under  such  treatment  healthy  granulations  may 
entirely  disappear,  and  the  cut  surface  assume  a  mucous-membrane- 
like appearance  and  so  remain.  Standing  or  walking  always  delays, 
and  may  sometimes  entirely  prevent  healing.  The  same  result  may 
follow  the  use  of  too  powerful  antiseptic  solutions  in  the  hands  of  an 
enthusiastic  dresser  in  hospital. 

During  the  treatment  the  burrowing  of  pus  and  the  formation  of 
a  new  pocket  should  always  be  carefully  watched  for  and  met  by 
incision. 

The  hemorrhage  in  an  ordinary  operation  for  fistula  is  seldom 
profuse  enough  to  cause  the  surgeon  any  uneasiness,  and  is  almost 
always  easily  controlled  by  packing  the  incision  with  gauze  and 
making  firm  pressure  with  a  compress  held  in  place  by  a  T-bandage. 
A  free  arterial  hemorrhage  from  a  vessel  well  up  to  the  rectum  must 
be  treated  either  by  ligature  or  tampon. 

Under  the  most  favorable  conditions  a  fistula  which  is  but  a 
straight  track  may  require  so  large  an  incision  that  a  couple  of 
months  may  be  required  for  healing.  In  some  cases  this  long  delay 
may  be  avoided  by  a  simple  method  of  introducing  deep  sutures  to 
approximate  the  sides  of  the  cut.  The  old  pyogenic  membrane  must 
first  be  completely  removed  and  the  track  put  into  condition  to  heal 
by  first  intention.  Two  or  three  wire  sutures  are  then  introduced  to 
draw  the  deeper  parts  of  the  cut  together,  and  the  edges  are  approx- 


FISTULA.  107 

imated  carefully  with  catgut.  If  the  attempt  be  successful  much 
time  will  be  saved,  and  If  it  fail  nothing  is  lost  ;  but,  except  in  slight 
cases  with  a  straight  track  and  easily  approximated  edges,  the  at- 
tempt at  union  by  first  intention  will  fail. 

The  general  idea  of  the  operation  of  cutting  a  fistula  in  ano,  is 
that  a  director  should  be  introduced  into  the  external  orifice,  brought 
out  into  the  rectum  through  the  internal  opening,  or  at  a  point  where 
its  end  approaches  most  nearly  to  the  mucous  membrane,  then  bent 
and  brought  out  of  the  anus,  and  that  the  tissues  upon  it  should  be 
cut. 

This  is  the  idea  conveyed  to  the  student  by  his  lectures,  and  to 
the  practitioner  by  his  text-books  on  general  surger}^ ;  and  in  many, 
perhaps  the  majority,  of  cases  this  simple  procedure  will  be  curative, 
for  many  fistulse  are  straight  tracks  running  not  very  deeply  into  the 
tissues,  and  it  is  to  them,  and  to  them  only,  that  the  operation  ap- 
plies. But  no  practitioner  will  cut  many  fistulse  in  this  ofl'hand,  rou- 
tine way  before  meeting  with  a  case  in  which  such  an  operation  will 
either  prove  a  signal  failure  or  will  result  in  irreparable  injury  to  the 
parts.  It  is  a  fact,  I  believe,  that  fully  fifty  per  cent,  of  all  opera- 
tions for  fistula,  even  in  hospital,  are  failures,  either  from  faults  in 
the  operation  or  lack  of  care  in  the  after-treatment. 

Perhaps  the  first  lesson  taught  by  an  unexpected  failure  in  effect- 
ing a  cure  by  this  operation  is  that  a  fistulous  track  is  something  to 
be  followed  by  a  careful  dissection,  and  not  a  thing  to  be  laid  open 
by  a  single  sweep  of  the  knife  along  a  director  which  has,  by  more  or 
less  force,  been  entered  at  one  opening  and  made  to  pass  out  at 
another  ;  for  by  this  course  not  only  is  the  track  often  left  in  great 
part  undivided,  but  the  director  is  forced  into  healthy  tissue  and 
parts  are  needlessly  sacrificed. 

Instead  of  this,  the  track  should  be  followed,  step  by  step,  from 
ics  external  opening  along  its  whole  course  ;  and  to  do  this  the 
director  need  only  be  introduced  a  short  distance  at  a  time  or  not  at 
all.  By  thus  following  carefully  the  course  of  the  fistula,  and  dis- 
secting it  out  to  its  end,  no  unnecessary  sacrifice  is  made  of  adjacent 
healthy  tissue,  and  side  tracks  or  diverticula  are  recognized  as  they 
are  met.  This  is  much  easier  than  to  pick  them  out  in  the  bottom  of 
an  extensive,  bleeding,  and  irregular  wound. 

A  word  about  the  director.  The  one  ordinarily  used  (Fig.  70)  is 
too  blunt  at  the  end  for  fine  work.  It  should  be  of  steel,  delicately 
made,  and  probe-pointed  ;  silver  is  too  flexible  for  ordinary  work. 
These  have  been  made  for  me  in  three  sizes  (Fig.  71). 


108  SURGERY   OF   THE   RECTUM   AlfD   PELVIS. 

With  regard  to  side  tracks  or  branching  diverticula,  the  rule  is 
that  all  such  should  be  dissected  up  exactly  as  the  main  track  should 
be  ;  but  to  this  there  are  very  important  exceptions.  The  rule  may 
perhaps  be  modified  in  this  way  :  As  many  tracks  should  be  divided 
as  can  be  done  without  risk  of  incontinence  of  faeces  in  either  sex,  or 
of  destruction  of  the  perineum  in  women,  or  of  too  great  injury  for 
the  reparative  powers  of  the  patient. 

As  a  rule,  both  the  sphincters  in  either  sex  may  be  divided  once 
in  the  median  line  without  danger  of  incontinence.    It  is  better,  how- 


FiG.  70. 

ever,  to  divide  as  little  as  possible.  The  inner  should  be  left  intact, 
if  possible  ;  the  division  should  be  straight  across  the  muscular  fibre, 
and  not  slanting  ;  and  a  double  division  of  one,  and  especially  of  both 
sphincters,  should  not  be  resorted  to  as  a  primary  operation,  unless 
with  the  distinct  understanding  on  the  part  of  the  patient  that  more 
or  less  incontinence  may  be  the  result.  In  operating  for  fistula,  no 
matter  how  simple,  it  is  well  to  be  on  guard  against  the  patient  who 
is  subject  to  intestinal  catarrh  with  diarrhoea,  either  constantly  or  at 
intervals.  A  sphincter,  the  sufficiency  of  which  would  never  be 
questioned  by  one  whose  bowels  act  naturally  once  a  day,  may  be  a 
cause  of  great  unhappiness  during  even  a  slight  attack  of  diarrhoea  ; 
and  a  single  cut  through  the  external  muscle  may  lead  to  this  result 
in  a  strong  man.      Stretching  the  muscle  may   do  the  same.      In 


G.T\tN\^<\W8<.Ca. 


Fig.  71. 

women  and  feeble  patients  there  is  more  risk  than  in  men  otherwise 
healthy. 

In  these  modifications  of  the  rule  of  complete  division  cases  of 
tracks  running  upward  along  the  bowel  are  not  included,  for  these 
should  be  divided  as  are  those  nearer  the  anus.  Here  the  supposed 
danger  of  hemorrhage  often  stops  the  operator  with  his  work  half- 
completed  ;  and  one  of  these  tracks  will  often  heal  spontaneously 
after  the  opening  of  the  lower  one  into  which  it  empties.  But  it  is 
not  safe  to  trust  to  this  chance.     These  upward  branches  are  of  two 


FISTULA. 


109 


distinct  kinds.  In  one  the  track  runs  directly  beneath  the  mucous 
membrane,  and  may  be  so  found  with  the  director  ;  and  in  this  there 
is  little  danger  of  hemorrhage  in  its  division,  for  the  blood-vessels 
are  all  outside  of  it.  In  the  other  variety  the  track  runs  deeper  in 
the  wall  of  the  gut,  under  the  muscular  layers,  perhaps  even  away 
from  the  rectal  wall  into  the  perirectal  tissues.  In  such  cases  there 
is  great  danger  of  hemorrhage,  and  the  amateur  surgeon  may  easily 
get  beyond  his  depth. 

The  exceptions  to  this  rule  of  complete  division  will  be  found  in 
three  classes  of  cases — those  of  the  horseshoe  variety,  the  recto- 
labial  variety,  and  the  old  cases  of  extensive  disease  where  the  whole 
anal  and  perineal  regions  are  riddled  with  openings.  In  these  cases 
all  the  ingenuity  the  operator  possesses  will  be  demanded  to  effect  a 
cure  without  resulting  incontinence. 

Horseshoe  fistula  has  been  defined  differently  by  different  writers. 
In  a  typical  case  it  is  a  form  of  fistula  in  which  there  are  one  or  more 
external  openings  on  each  side  of  the  anus  and  an  inner  opening  in 
the  rectum  in  the  median  line  behind.     It  is  shown  in  Fig.  72.     But 


Pig.  72. 


a  horseshoe  fistula  may  have  only  one  external  opening,  and  yet  the 
abscess  which  has  caused  it  may  entirely  surround  the  gut  in  horse- 
shoe form.  N"or  need  the  internal  orifice  be  in  the  median  line, 
either  behind  or  in  front.  The  name  applies  to  the  shape  of  the  ab- 
scess which  has  resulted  in  fistula,  and  not  at  all  to  the  location  of 
the  openings.     In  this  form  of  disease  the  pus  in  its  burrowing  has 


110 


SURGERY   OF   THE   RECTUM   AND   PELVIS. 


extended  from  one  side  of  the  gut  to  the  other,  and  the  resulting 
fistula  may  be  complete,  incomplete,  or  of  the  blind  internal  variety. 
The  internal  opening  may  be  at  any  point,  and  the  external  may  be 
on  the  opposite  side  of  the  body  from  it. 


Fig.  73. 


In  these  cases  I  think  it  will  generally  be  observed  that  the  open- 
ings do  not  lead  into  distinct  fistulous  tracts  of  any  great  extent,  but 
rather  into  one  abscess  cavity  of  considerable  size. 


Fig.  74. 


It  is  evident  that  in  operating  upon  such  cases  as  these  there  is  a 
chance  for  much  skill  in  effecting  a  cure  at  one  operation  and  still 
preserving  the  sphincteric  power.     And  I  may  say  that  a  patient 


FISTULA, 


111 


who  has  been  left  with  incontinence  of  faeces  after  this  operation  is 
apt  to  be  very  unforgiving,  especially  when  it  happens  to  be  a  lady 
who  has  been  rendered  loathsome  to  herself,  afraid  to  trust  herself  in 
society,  and  doomed  to  the  constant  wearing  of  a  napkin.     I  have 


Fxa.  r:>. 


seen  several  such,  and  by  means  to  be  referred  to  have  relieved  some, 
but  from  the  ill-fortune  of  others  I  have  come  to  warn  my  own 
patients  that  incontinence  may  possibly  result,  when  I  see  any 
reason  to  anticipate  such  a  conclusion. 


Fig. 


Taking  now  a  case  of  horseshoe  fistula,  such  as  is  shown  in 
Fig.  72.  The  ordinary  operation  would  consist  in  two  complete 
divisions  of  the  sphincters  on  opposite  sides  (Fig  73),  probably  re- 
sulting in  incontinence.  The  correct  method  consists  in  one  com- 
plete posterior  division,  and  then  the  opening  of  the  lateral  tracks 
into  this  posterior  cut,  as  shown  in  Fig.  74. 


112 


SURGERY    OF   THE    RECTUM    AND    PELVIS. 


This  principle  may  be  made  to  cover  nearly  all  of  this  class  of 
cases.  Where  several  external  openings  are  grouped  around  the 
anus  they  may  all  be  connected  by  one  incision,  and  from  this  incision 


Fig.  77. 


a  probe  may  be  passed  through  the  internal  opening,  and  this,  too, 
divided  with  the  sphincter. 

A  more  complicated  case  of  the  same  variety  is  shown  in  Fig.  75, 
and  the  incisions  by  which  it  may  be  cured  with  but  a  single  division 
of  the  sphincter  are  shown  in  Fig.  76. 


Fig.  78. 


In  case  the  external  opening  be  at  a  considerable  distance  from 
the  anus,  and  on  the  opposite  side  of  the  body  from  the  internal,  as 


FISTULA. 


113 


shown  in  Fig.  77,  the  method  is  essentially  the  same,  the  thing  to  be 
avoided  being  a  slanting  cut  through  the  rectum  and  healthy  tissue. 
By  following  the  ordinary  rule  in  such  a  case — passing  a  director 
into  one  opening  and  out  of  the  other,  and  cutting  upon  it — all  but  a 
small  portion  of  the  lower  end  of  the  bowel  would  be  completely 
severed  by  a  deep  incision.  Fig.  78  shows  the  cuts  that  were  made 
by  which  a  cure  was  effected  without  incontinence. 

It  may  easily  occur  that  in  a  complicated  case  it  is  found  im- 
possible to  divide  all  of  the  tracks  without  a  double  or  even  triple 


Fig.  79. — Vulvar  Abscess. 


division  of  the  muscles.  In  such  cases  the  safer  practice  is  to  do 
such  an  operation  as  has  been  indicated  upon  all  the  tracks  that  can 
be  included  in  a  single  division  of  the  muscle,  and  to  trust  to  other 
means  of  cure  for  ,the  balance,  at  least  till  the  first  wound  has 
healed. 

The  second  class  of  cases  in  which  it  may  be  unjustifiable  to 
divide  all  the  tracks  at  the  primary  operation  is  that  of  the  recto- 
labial  fistulse. 

This  form  of  disease  is  in  most  cases  due  to  inflammation  of  one 
or  both  vulvo-vaginal  glands  or  their  ducts,  leading  to  suppuration 
and  the  final  escape  of  pus,  both  on  the  labia  and  within  the  rectum 
(Fig.  79).     There  may  be  numerous  external  and  internal  openings. 


114 


SURGERY    OF   THE    RECTUM    AND    PELVIS. 


In  the  case  shown  in  Fig.  80  there  were  three  distinct  abscesses,  one 
in  each  labium  and  one  near  the  anus,  unconnected  with  each  other, 
and  only  one  of  which  connected  with  the  gut.  In  the  case  shown 
in  Fig.  81  there  was  a  labial  opening  on  each  side.  The  right  track 
had  opened  on  the  anterior  wall  of  the  rectum  in  two  places,  the  left 
in  one,  and  the  right  and  left  tracks  communicated  by  a  submucous 
track  in  the  rectum.     In  such  a  case  the  division  of  both  tracks 


would  result  in  a  complete  double  division  of  the  whole  perineum,  as 
well  as  the  external  sphincter. 

The  cuts  made  at  the  primary  operation  are  shown  in  Fig.  82. 

A  probe  was  first  passed  through  the  track  on  the  right  side,  from 
the  external  opening  down  to  the  verge  of  the  anus,  its  end  cut  down 
upon  and  brought  out  through  the  skin  of  the  perineum  at  the  point 
B.  From  this  point  it  was  carried  along  the  fistula  to  the  internal 
opening  on  the  same  side,  and  this  part  of  the  track  divided  with  the 
sphincter.  The  director  was  then  again  passed  from  the  opening  D 
to  the  first  cut,  and  the  cross-track  divided.  Finally  all  of  the  sub- 
mucous tracks  were  slit  up,  and  the  track  on  the  left  side  from  its 


FISTULA.  115 

internal  opening  as  far  as  was  possible  without  complete  division  of 
the  spliincter  at  that  point.  Setons  were  then  passed  along  what  re- 
mained of  the  original  tracks,  and  tied.  The  result  was  a  perfect 
cure  without  incontinence. 

The  only  rational  treatment  for  the  ordinary  blind  internal  forms 
of  fistula  is  by  incision  into  the  gilt.  The  only  exception  to  this  is 
in  acute  cases  of  ischio-rectal  abscess  seen  within  a  day  or  two  after 
the  pus  has  forced  its  way  into  the  gut.  In  such,  a  free  external 
incision  and  a  thorough   cleaning  out  of  the  abscess   cavity  may 


Ai 


&.  c^ 


^R 


/(i-r-=-    0  \ 


H 


xy 


Fig.  81. — Recto-Labial  Fistula. 

avoid  the  necessity  for  cutting  into   the  bowel  and  dividing  the 
sphincters. 

Where  the  probe  readily  enters  from  the  gut  an  abscess  cavity 
or  a  track  running  downward  toward  the  skin,  it  should  be  bent  into 
a  hook,  brought  as  near  the  surface  as  possible,  and  a  counter-open- 
ing made  upon  it.  Through  these  two  openings  a  director  should  be 
passed  and  the  whole  cavity  laid  open  into  the  gut.  In  whatever 
direction  the  track  leads,  it  must  be  followed  to  its  end  and  freely 
divided.  Much  delicacy  and  patience  are  sometimes  necessary  to 
accomplish  this  so  that  no  side  tracks  are  missed ;  the  probes  and 
directors  may  need  to  be  very  delicate,  and  much  time  may  be  re- 
quired ;  but  the  success  of  the  operation  depends  upon  the  thorough- 


116 


SURGERY    OF   THE   RECTUM   AND   PELVIS. 


ness  with  which  it  is  done.  Free  drainage  at  the  most  dependent 
part  of  the  incision  should  always  be  provided,  and  to  do  this  it  may- 
or may  not  be  necessary  to  cut  deeply  through  the  sphincters.  There 
is  always  more  or  less  induration  around  an  old  fistula  and  when  this 


Fig    82  —Incisions  foi  Recto  Labial  Fistula 


can  be  felt  through  the  skin  I  have  often  cut  directly  down  upon  it 
without  any  director  through  the  internal  orifice,  and  have  then 
found  no  diflaculty  in  passing  a  director  onward  to  the  internal  ori- 
fice. 


Pig.  83.— Fistula  Knife 


The  knife  shown  in  Fig.  83  with  flexible  probe  point  will  often  be 
found  useful. 

Large  abscesses  of  the  pelvis  in  the  male,  which  have  opened  into 
the  rectum  should  be  treated  by  the  introduction  of  a  drainage-tube 
and  daily  washing  out  with  boracic  acid  solution.     Those  located  in 


FISTULA.  117 

the  ischio-rectal  fossa  should  be  opened  on  the  skin,  thoroughly 
cleaned  out,  and  treated  by  drainage  and  injections  to  give  the  inter- 
nal opening  a  chance  to  close  without  dividing  the  tissue  betv^een 
the  two  openings,  which  is  often  considerable.  Should  this  fail  the 
ordinary  operation  may  be  done. 

In  fistulse  with  very  long  and  deep  tracks,  or  in  those  with  many 
smaller  ones,  a  cure  without  an  amount  of  cutting  which  shall  neces- 
sarily lead  to  incontinence  may  be  impossible.     Fig.  84  is  taken  from 


"^r 


«-^?<^'- 


•v. 


Fig.  84.— Cicatrix  of  Fistula. 

a  case  of  the  latter  variety,  where  the  openings  and  tracks  were  so 
numerous  and  the  patient's  general  condition  so  bad,  that  a  cure  was 
for  some  time  despaired  of.  By  several  operations,  however,  under- 
taken at  intervals,  they  were  all  finally  laid  open  and  cured,  with 
the  result  shown. 

In  the  case  shown  in  Fig.  85  the  external  opening  was  over  the 
great  trochanter,  and  the  case  was  very  naturally  mistaken  for  hip- 
joint  disease  by  several  operators. 

The  cause  of  incontinence  after  operations  for  fistula  has  been 
the  subject  of  considerable  argument,  for  in  some  cases  a  single  in- 


118 


SURGERY  OF  THE  RECTUM  AND  PELVIS. 


cision  through  the  external  sphincter  has  been  followed  by  this  unto- 
ward accident,  while  in  others  very  extensive  and  numerous  incisions 
have  left  the  patient  still  with  good  control.  Smith  believes  it  to  be 
due  not  so  much  to  the  division  of  the  sphincters  as  to  division  of 
the  circular  muscular  fibres  of  the  lower  part  of  the  rectum  ;  while 
Esmarch  holds  rather  to  the  theory  that  it  is  due  to  division  of  the 
nerves  supplying  the  muscle  more  than  to  the  division  of  muscular 
fibres. 


Fig    85  — Cicatrix  of  Fistula 


In  my  own  mind  the  explanation  lies  in  the  fact  of  vicious  cicatri- 
zation, by  which  the  ends  of  the  divided  muscles  are  not  brought  into 
apposition  in  healing.  On  this  supposition  it  is  easy  to  understand 
why  a  single  cut  may  result  in  loss  of  muscular  power,  the  ends  of 
the  sphincter  being  separated  by  an  interval  of  half  an  inch,  and  the 
muscle  therefore  having  no  fixed  point  of  support ;  while  in  other 
cases  several  incisions  which  have  healed  properly  may  still  leave 
the  segments  of  the  muscle  in  shape  to  act  as  one  undivided  circle. 
The  simplest  form  of  the  same  condition  is  seen  in  lacerated  perineum 
in  the  female.  Here  a  single  rent  is  followed  by  almost  complete  in- 
continence ;  and  although  the  perineum  may  seemingly  be  perfectly 
restored  by  operation,  there  will  be  no  return  of  sphincteric  power 


FISTULA.  119 

till  the  cut  and  separated  ends  of  the  muscle  are  brought  into  appo- 
sition. 

The  condition  is  one  which  entails  a  greater  or  lesser  degree  of 
misery,  depending  upon  the  consistence  of  the  fgeces  and  the  regu- 
larity with  which  they  are  voided.  To  a  man  who  has  one  solid, 
natural  evacuation  before  going  from  his  house  in  the  morning,  there 
may  be  no  suffering  and  little  annoyance,  except  what  arises  from 
the  involuntary  escape  of  wind  and  the  soiling  of  the  person  with 
the  natural  mucous  secretion  of  the  bowel.  The  fact  of  inability  to 
control  the  passage  does  not  necessarily  imply  that  the  passages 
escape  in  a  way  to  cause  annoyance,  for  when  they  are  of  natural 
consistence  and  passed  with  regularity  there  is  generally  sufficient 
warning  to  allow  the  patient  to  seek  the  closet,  which  he  has  learned 
never  to  be  far  away  from  at  a  certain  hour.  The  greatest  suffering 
comes  in  women  when  the  bowels  are  loose  ;  then  there  is  absolutely 
no  chance  to  avoid  the  consequences ;  a  napkin  is  constantly  worn, 
and  the  patient  soon  becomes  a  confirmed  invalid. 

If  the  anus  be  open  and  patulous,  more  or  less  prolapsus  may 
follow ;  and  this  is  a  fresh  cause  of  tenesmus  and  discharge,  compli- 
cating and  increasing  the  original  trouble.  The  train  of  nervous 
symptoms  following  this  condition  is  often  in  itself  serious,  and  ap- 
parently out  of  proportion  to  the  physical  disabilitj^ 

In  the  treatment  of  this  condition  the  operator  has  an  ample  field 
for  the  exercise  of  all  his  ingenuity,  for  no  two  cases  will  be  found 
exactly  alike,  and  the  operations  must  vary  accordingly. 

Some  will  be  seen  at  a  glance  to  be  manifestly  incurable — such, 
for  example,  as  the  one  shown  in  Fig.  85,  where  the  sphincters  have 
been  cut  again  and  again  in  different  directions  till  the  anus  has  lost 
entirely  its  original  shape,  and  it  would  be  difficult  to  find  any  trace 
of  the  sphincter  by  the  most  careful  dissection.  Most  cases,  however, 
are  amenable  to  operation  and  relief,  and  a  successful  operation 
brings  much  sincere  gratitude  to  the  operator. 

There  are  two  guiding  principles  in  operating.  The  first  is  to  find 
the  ends  of  the  sphincter  and  unite  them  by  suture  ;  the  second  is 
applicable  where  the  first  is  impossible,  and  consists  in  producing  an 
artificial  tightening  and  closure  of  the  anus  without  much  regard  to 
sphincteric  action. 

The  first  indication  may  often  be  followed  out  at  the  time  of  the 
original  operation  for  fistula,  and  is,  in  fact,  done  in  the  operation 
for  immediate  closure  of  the  incision  by  suture  of  the  wound,  under 


120 


SURGERY    OF   THE    RECTUM   AND   PELVIS. 


antiseptic  precautions.  In  extensive  tracks  and  abscess  cavities  the 
operation  may  fail,  but  in  single  deep  cuts  it  often  succeeds,  and  it 
is  always  worthy  of  trial  with  the  object  of  obtaining  direct  and  im- 
mediate union  of  the  ends  of  the  muscle  and  avoiding  possible  incon- 
tinence. 

In  cases  such  as  are  shown  in  Figs.  86  and  87  the  operation  is  the 
same  as  in  lacerated  perineum — cutting  down  upon  the  ends  of  the 
muscle,  freshening  the  edges  of  the  original  incision,  and  bringing 
them  together  with  wire  or  catgut  sutures. 

In  a  case  such  as  is  shown  in  Fig.  88  the  operation  is  much  more 
complicated.     This  patient,  in  spite  of  all  the  cutting  which  had  been 


'■JS^'^"-^^  , 


Fig.  86. 


Fig.  87. 


done,  was  still  suffering  from  a  blind  internal  fistula  when  he  came 
under  my  care.  In  the  figure  the  parts  are  not  at  all  stretched  open. 
The  anus  is  seen  as  an  irregular  circle  composed  of  cicatricial  tissue, 
which  held  it  wide  open.  The  cicatrix  extended  an  inch  and  a  half 
into  the  rectum  on  all  sides,  and  no  mucous  membrane  was  seen  till 
beyond  this  point.  The  anus  and  lower  part  of  the  rectum  presented 
an  open  tube  about  an  inch  in  diameter,  entirely  without  any  power 
of  muscular  contraction.  At  the  point  where  the  folds  of  mucous 
membrane  first  appeared  there  was  an  opening  leading  into  a  deep 
sinus  in  the  right  buttock,  and  this  was  opened  up,  relieving  the  pa- 
tient of  the  pain  and  purulent  discharge  from  wdiich  he  suffered. 

Even  in  this  case,  with  anus  and  lower  part  of  rectum  converted 
into  an  open,  unyielding  tube,  the  patient  did  not  complain  of  incon- 


FISTULA. 


121 


tinence,  though  there  could  have  been  no  action  of  either  sphincters 
or  levator,  and  hence  no  control.  He  simply  had  a  natural  passage 
ever}^  morning  and  was  never  subject  to  diarrhoea. 

In  such  a  case  the  anus  could  only  be  closed  by  a  plastic  opera- 
tion. The  plan  I  proposed  was  to  dissect  the  mucous  membrane 
loose,  draw  it  down,  and  stitch  it  to  the  skin,  after  freshening  the 
cicatricial  ring  of  the  anus  so  as  to  first  give  a  mucous  lining  to  the 
parts  ;  then,  by  a  subsequent  plastic  operation,  or  perhaps  by  the 
cautery  iron,  to  close  the  outlet  of  the  canal.  But  after  the  fistula 
was  cured,   the  patient,  suffering  really  no  inconvenience,  declined 


■r 


M 


Fig.  88. — Incontinence  after  Fistula. 


further  operation.  The  case  proves,  better  than  any  I  have  ever  seen, 
that  complete  loss  of  sphincteric  power  is  not  always  attended  by 
any  inconvenience. 

After  what  has  been  said  of  the  origin  and  extent  of  abscesses  of 
the  pelvis  it  is  evident  that  there  may  result  from  them  a  class  of 
fistulse  which  are  not  to  be  operated  upon  by  any  of  the  methods  we 
have  described — fistulse  so  deep  and  extensive  as  to  contra-indicate  all 
operative  interference.  And  yet  much  may  be  done,  even  in  the 
worst  cases  of  this  kind,  and  by  proper  treatment  many  may  be 
cured.  The  first  attempt  of  the  surgeon,  when  the  opening  of  the 
abscess  is  near  the  bowel  in  the  perineum,  should  always  be  toward 


122  SURGERY    OF    THE    RECTUM    AND    PELVIS. 

effecting  a  cure  without  cutting  the  track  into  the  bowel.  External 
and  comparatively  free  incisions  may  be  made,  which  shall  not  im- 
plicate the  anus,  and  through  them  drainage-tubes  maybe  passed 
into  the  abscess  cavity  so  that  it  may  be  freely  emptied.  Through 
the  drainage-tube   stimulating  injections  may  be  made,   and   the 


Fig.  89.— Result  of  Operation  for  Incontinence. 

abscess  treated  as  an  abscess  elsewhere  would  be,  by  rest  and  atten- 
tion to  the  general  health.  A  cure  may  sometimes  be  effected  in  this 
way  in  a  very  unpromising  case. 

Pelvic  abscesses  which  have  opened  far  away  from  the  bowel,  as  in 
the  loins  or  buttocks,  must  be  treated  on  general  sui-gical  principles. 
I  have  cured  one  in  a  woman  by  following  two  tracks  from  their  open- 
ings in  either  loin  down  into  the  pelvis  under  the  sacrum  and  thor- 
oughly draining  the  pelvic  abscess.  Grenerally,  however,  these 
must  be  treated  by  laparotomy,  the  abscess  being  first  attached  and 
the  sinus  being  subsequently  induced  to  heal  if  possible. 

In  fistula  complicating  stricture  of  the  rectum,  attention  should 
always  first  be  turned  to  the  latter  ;  for  if  this  can  be  cured  there  is 
a  prospect  that  the  former  may  undergo  spontaneous  closure,  and  if 


FISTULA. 


123 


the  stricture  be  not  relieved  it  will  be  of  little  avail  to  cut  the  fistula. 
Many  awkward  mistakes  have  happened  to  good  surgeons  by  failing 
to  detect  this  complication  of  diseases. 

Becto-uretJiral  Mstula.— This  is  generally  due  either  to  direct 
traumatism,  surgical  or  otherwise,  or  to  some  ulcerative  or  suppura- 
tive process.  The  operation  usually  performed  to  cure  the  condition 
consists  in  making  two  flaps  from  the  mucous  membrane  of  the  rec- 
tum, turning  their  raw  surfaces  toward  the  urethra,  and  suturing 
them  there.  All  antiseptic  precautions  should  be  carefully  carried 
out. 

With  a  scalpel  an  incision  (Fig.  90  AAA)  is  made  around  the  fis- 
tula, extending  entirely  through  the  mucous  membrane  of  the  rec- 
tum, which  is  opened  as  widely  as  possible  with  a  speculum.  The 
flaps  thus  marked  out  are  dissected  loose  from  circumference  toward 
the  opening  until  the  line  BBB  is  reached,  and  must  depend  for  their 
nourishment  upon  the  space  left  between  the  line  B  and  the  edge  of 


Fig.  90.— Operation  for  Recto-Urethral  Fistula, 

the  fistula.  The  raw  surfaces  of  the  two  flaps  are  then  turned  toward 
each  other  and  the  urethra  and  sutured  in  this  position  with  fine 
chromicized  gut,  which  is  buried  in  the  substance  of  the  flap  so  as 
not  to  appear  on  the  urethral  surface.  A  catheter  should  be  tied 
into  the  bladder,  and  three  times  a  day  the  bladder  should  be  irri- 


124  SURGERY   OF   THE   RECTUM    AND   PELVIS. 

gated  with,  a  boric  acid  solution.  Tlie  bowels  should  be  moved  on 
the  third  day. 

Intestino-vesical  Fistula. — The  majority  of  these  cases  will  be 
found  due  to  abscesses,  next  in  frequency  come  those  caused  by 
cancer,  and  finally  those  said  to  be  due  to  simple  ulceration.  When 
the  faeces  pass  from  the  rectum  to  the  bladder  an  amount  of  local  and 
constitutional  disturbance  will  result  which  generally  renders  the 
condition  a  fatal  one  unless  the  communication  be  closed  by  surgical 
operation. 

An  effort  should  first  of  all  be  made  to  decide  upon  the  point  of 
intestine  involved — whether  it  be  in  the  small  or  large  bowel.  Digital 
examination  per  rectum  may  reveal  a  cancerous  stricture,  in  which 
case  it  is  fair  to  conclude  that  the  opening  is  near  the  disease  and 
caused  by  it,  either  by  direct  extension  of  the  malignant  process,  or 
as  a  result  of  secondary  inflammation  and  abscess. 

The  character  of  the  faeces  passed  in  the  urine  may  also  give 
valuable  information.  If  food  be  passed  undigested,  an  opening  in 
the  small  bowel  may  be  inferred.  If,  on  the  other  hand,  the  faeces 
be  well  formed,  it  is  probable  that  the  communication  is  either  in 
the  sigmoid  flexure  or  rectum.  The  injection  of  milk  into  the 
rectum  and  its  prompt  appearance  in  the  urine  is  the  surest  of  all 
indications  that  the  opening  is  near  the  rectum.  In  sixty-three  cases 
collected  by  Cripps,  the  communication  was  rectal  in  twenty-five,  in 
the  colon  in  fifteen,  and  in  the  small  intestine  in  twelve. 

The  treatment  consists  in  perineal  section  for  the  drainage  of  the 
bladder,  in  supra-pubic  cystotomy  for  drainage,  and  also  for  the 
possibility  of  closing  the  fistula  from  the  vesical  side  ;  and  finally  in 
coeliotomy  to  discover  the  exact  nature  and  location  of  the  fistula. 
With  the  abdomen  open,  it  may  be  possible  to  close  the  fistula  by 
plastic  work,  and,  failing  in  this,  a  colostomy  is  always  indicated 
when  the  disease  is  in  the  large  bowel  and  the  artificial  anus  can  be 
safely  formed  above.  In  cases  of  fistula  between  the  rectal  pouch 
and  the  bladder,  an  operation  by  means  of  Kraske' s  incision,  with  free 
posterior  longitudinal  division  of  the  rectum,  may  hold  out  a  prospect 
of  success.  These  cases  are  fortunately  rare,  and  in  those  of  cancer- 
ous origin  colostomy  will  afford  all  the  relief  possible.  In  colostomj'' 
for  this  purpose  the  gut  should  be  cut  completely  across,  and  the 
distal  end  invaginated  and  dropped.  No  chances  should  be  taken 
of  the  possibility  of  any  faeces  passing  into  the  gut  below  the  artificial 
anus  (Fig.  91) 


FISTULA. 


125 


.1. 

•'a 


Pv. 


Pig.  91. 
Intestino-vesical  Fistula  and  Colostomy. 


126  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

In  the  two  cases  of  this  disease  on  which  I  have  operated,  the 
fistula  in  one  was  due  to  abscess  following  the  division  of  a  stricture, 
and  in  the  other  to  an  abscess  complicating  a  cancer  of  the  rectum. 

Intestino-ziaginal  Fistula. — As  in  intestino-vesical  fistula,  so  here 
the  communication  may  be  either  with  the  rectum,  or  with  any  part 
of  the  large  or  small  intestine  above  the  rectum.  When  the  opening 
is  rectal  it  will,  in  the  great  majority  of  cases,  be  due  to  laceration  in 
delivery,  although  wounds,  ulcerations,  and  malignant  disease  all 
play  a  part  in  the  etiology.  When  the  opening  is  above  the  rectum, 
it  may  be  due  to  cancer,  to  abscess  following  non-malignant  strict- 
ure of  the  rectum,  to  direct  wounding  of  the  intestine  in  vaginal  or 
abdominal  coeliotomy,  or  to  rupture  of  the  vagina  during  labor, 
with  protrusion  and  strangulation  of  a  coil  of  intestine  through  the 
laceration. 

In  these  cases  where  the  fistula  is  above  the  rectum,  after  efforts 
to  secure  closure  by  cauterization  have  been  unsuccessful  (they 
should  only  be  tried  in  cases  of  small  openings),  the  surgical  pro- 
cedure will  at  first  depend  upon  the  extent  of  the  fistula.  If  it  be 
small  and  the  rectum  beyond  it  be  free,  plastic  work  through  the 
vagina  may  be  successful.  If,  on  the  other  hand,  it  be  large  and 
practically  forms  the  end  of  the  alimentary  canal  as  far  as  the  pas- 
sage of  faeces  is  concerned,  a  laparotomj^  is  indicated.  With  the 
abdomen  opened,  the  gut  may  be  dissected  loose  and  closed ;  the 
piece  may  be  resected  entirely  and  an  anastomosis  established,  or  if 
this  prove  impossible,  a  colostomy  may  be  resorted  to.  Should  it 
seem  that  a  vaginal  anus  offers  little  advantage  over  an  inguinal  one, 
the  intense  vaginitis  resulting  from  these  cases  need  only  be  called 
to  mind. 

Becto-Tiagmal  Fistula,  when  small,  may  be  treated  by  cauteriza- 
tion. When  larger,  or  when  cauterization  has  been  tried  and  failed, 
they  are  best  sutured  from  the  vaginal  surface.  The  vaginal  mucosa 
should  be  dissected  off  for  a  considerable  space  around  the  fistula, 
and  the  lining  of  the  fistula  itself  should  be  thoroughly  removed 
down  to  the  rectal  mucosa.  The  suture  may  be  continuous,  of  fine 
chromicized  gut,  and  should  not  perforate  the  rectum.  In  bad  cases 
it  may  be  necessary  to  make  free  incisions  into  the  septum  to  allow 
of  approximation  of  the  edges,  or  to  stitch  the  anterior  lip  of  the 
cervix  to  the  lower  margin  of  the  perforation,  thus  closing  the  com- 
munication between  rectum  and  vagina,  but  turning  the  menstrual 
dischar£i:e  into  the  rectum. 


FISTULA.  127 

The  method  by  flap-splitting  consists  in  passing  one  or  two  fin- 
gers into  the  rectum  for  a  guide  and  support,  and  splitting  the  edges 
of  the  perforation  all  around  with  scalpel  or  fine-pointed  scissors. 
The  rectal  and  vaginal  walls  should  be  separated  from  each  other  for 
at  least  half  an  inch. 

Through  the  vagina  unite  first  the  rectal  edges  and  then  the 
vaginal  edges.  The  sutures  uniting  the  rectal  edges  will  be  buried 
in  the  recto-vaginal  septum  when  the  vaginal  edges  are  sutured 
over  them. 

The  first  sutures  should  be  entirely  in  the  rectal  wall  and  should 
not  pass  into  either  the  vaginal  or  the  rectal  canal.  A  small  full 
curved  Hagedorn  needle,  armed  with  fine,  fully  chromicized  catgut 
is  best  for  the  purpose.  The  flap  of  vaginal  mucosa  is  pulled  aside 
and  the  needle  is  entered  under  it  in  the  substance  of  the  rectal  wall 
brought  out  at  the  edge  of  the  fistula,  entered  again  at  the  edge  op- 
posite and  brought  out  one- third  or  one-half  an  inch  from  the  edge. 

After  the  rectal  flaps  have  been  united  in  this  way,  the  vaginal 
flaps  are  united  by  a  similar  suture,  and  the  former  one  is  completely 
buried.  Fine  gut  should  be  used  and  buried  knots  cut  as  short  as 
safety  allows. 

The  vagina  should  be  lightly  packed  with  iodoform  gauze  and  the 
urine  drawn  till  the  gauze  has  been  removed  after  the  first  few  days. 
The  bowels  should  be  moved  on  the  third  day  by  laxatives  and 
enema,  and  the  sphincter  should  be  stretched  at  the  time  of  opera- 
tion. 


CHAPTER  IX. 

HEMORRHOIDS. 

Although  hemorrhoids  may  be  defined  in  a  general  way  as  vari- 
cosities of  the  anal  or  rectal  vessels,  they  present  themselves  under 
so  many  different  forms  and  modifications  that  such  a  definition  con- 
veys but  little  idea  of  their  characteristics. 

For  convenience  they  may  be  divided  into  external  and  internal ; 
and  these  may  always  be  distinguished  from  each  other,  though  both 
may  exist  at  the  same  time  in  the  same  patient.  An  external  hemor- 
rhoid originates  in  the  subcutaneous  veins  which  surround  the  anus ; 
it  is,  therefore,  entirely  below  the  sphincter  muscle,  and  though  it 
may  be  partially  covered  by  mucous  membrane,  it  does  not  come 
from  the  rectum  proper,  nor  can  it  be  forced  above  the  external 
sphincter  muscle.  An  internal  hemorrhoid  originates,  on  the  other 
hand,  within  the  rectum,  and  may  exist  for  a  long  time  without 
appearing  externally.  When  it  does  show  itself  outside  of  the  anus, 
it  is  a  result  of  straining,  of  increase  in  size,  or  of  a  lax  condition  of 
the  sphincter  ;  and  after  long  exposure  outside  the  body  it  may  be- 
come changed  in  character  and  appearance  till  the  mucous  membrane 
covering  it  takes  on  something  of  the  character  of  integument ;  but 
it  may  still,  with  proper  management,  be  returned  within  the  bowel, 
though  it  may  not  remain  there  for  any  length  of  time. 

The  distinction  between  an  external  and  an  internal  hemorrhoid  is 
not  a  purely  arbitrary  one,  the  one  being  below  and  the  other  above 
the  external  sphincter.  A  different  set  of  blood-vessels  is  implicated 
in  each  case.  An  external  hemorrlioid  is  a  varicosity  of  an  external 
hemorrhoidal  vein,  and  is,  therefore,  an  affection  of  the  general 
venous  circulation.  An  internal  hemorrhoid  is  a.  varicosity  of  the 
middle  or  internal  hemorrhoidal  veins,  which  are  parts  of  the  visceral 
venous  system.  A  glance  at  the  venous  anatomy  of  the  rectum  and 
anus  will  show  the  arrangement  of  these  two  sets  of  veins,  and  will 
also  explain  how,  from  the  free  anastomosis  which  exists  between 


HEMORRHOIDS.  129 

them,  it  is  improbable  that  one  should  be  affected  without  influenc- 
ing the  other  to  a  greater  or  less  extent.  Other  secondary  differ- 
ences, which  may  arise  from  various  causes,  in  the  development, 
appearance,  and  characteristics  of  the  tumors,  will  be  considered 
later. 

External  Hemorrlioids. — A  person  of  middle  age  who  has  not  at 
some  time  suffered  from  an  external  hemorrhoid  is  indeed  a  rarity? 


Fig.  92. — External  Venous  Hemorrhoid. 

so  common  is  this  affection.  It  is  perhaps  useless  to  seek  for  the 
causes  of  a  malady  which  is  so  universal,  beyond  a  few  which  are 
well  recognized  and  manifest.  Amongst  these  are  straining  at  stool, 
pregnancy,  affections  of  the  internal  organs  which  interfere  with  the 
return  of  venous  blood,  and  constipation.  Outside  of  these  cases 
where  a  manifest  cause  exists,  external  hemorrhoids  will  be  found 
amongst  all  classes.  Those  who  smoke  and  those  who  do  not  ;  the 
high  liver  and  the  abstemious  ;  the  laborer  and  the  professional  man  ; 
those  who  stand  and  those  who  sit,  are  all  affected  about  equally. 

An  external  hemorrJioid  may  appear  in  two  different  forms,  which 
bear  little  resemblance  to  each  other.  The  first  is  a  small,  round  or 
elongated  venous  tumor  (Fig.  92). 

This  is  simply  an  extravasation  of  venous  blood  into  the  deli- 
cate subcutaneous  connective  tissue  of  the  anus.  The  patient,  often 
9 


130  SUKGEltY    OF   THE    RECTUM    AND    PELVIS. 

while  in  perfect  liealtli,  and  without  any  appreciable  cause,  feels  a 
sense  of  uneasiness  at  the  anus.  An  examination  made  by  himself 
shows  a  small,  soft,  painful  lump,  from  the  size  of  a  pea  to  that  of  a 
grape,  which  disappears  on  pressure,  but  immediately  returns.  This 
is  extravasated  venous  blood  from  a  previously  weakened  and  di- 
lated vein  which  has  ruptured.  After  a  few  hours  the  tumor  be- 
comes harder  and  more  painful,  and,  if  near  enough  to  the  surface 
for  the  blood  to  show  under  the  tense  skin,  it  will  appear  as  a  bluish 
black  circumscribed  swelling.  The  discomfort  caused  by  this  condi- 
tion is  out  of  all  proportion  to  its  apparent  magnitude.  The  patient 
generally  tries  to  keep  about,  but  can  neither  sit  nor  stand  with  any 
comfort.  The  pain  is  a  sort  of  dull  ache  which  it  is  very  lia-id  to 
bear,  and  to  gain  temporary  relief  efforts  are  generally  made  every 
little  while  to  force  the  lump  above  the  sphincter.  The  pressure 
often  gives  a  moment's  relief,  but  not  more,  for  the  tumor  does  nor 
come  from  above  the  sphincter  and  cannot  be  made  to  stay  there. 

When  left  to  its  own  course,  a  blood}^  tumor  of  this  variety  may 
gradually  decrease  in  size  from  the  absorption  of  the  fluid  elements 
of  the  clot,  the  pain  decreasing  at  the  same  time  ;  and  after  a  week 
or  ten  days  of  discomfort  it  is  changed  into  a  cutaneous  hemorrhoid. 
Or  the  opposite  course  may  be  taken,  and  the  tumor  may  show  all 
the  signs  of  an  abscess  and  finally  rupture  spontaneously  with  the 
discharge  of  a  little  blood  and  pus,  and  with  an  instantaneous  ending 
to  a  week  of  suffering. 

There  are  two  ways  of  treating  such  a  tumor.  The  first,  and 
best,  is  to  lay  it  freely  open  and  turn  out  the  clot  from  its  bed. 

If  the  surgeon  undertake  this  method  of  treatment,  there  are  one 
or  two  hints  which  may  be  of  value.  The  incision  itself  is  painful, 
and  should  therefore  be  done  with  a  sharp  bistoury  of  the  form 
shown  in  Fig.  93,  and  it  should  be  done  instantaneously.     Again, 


Fig.  93. 

care  should  be  exercised  to  empty  the  clot  entirelj^  out  of  its  bed, 
otherwise  a  small  wound  remains  which  will  not  readily  heal,  be- 
cause the  sac  is  prevented  from  contracting,  and  the  patient  is 
obliged  to  wear  a  bandage,  perhaps  for  a  week  or  longer,  to  keep 
from  soiling  the  linen  with  a  sanious  discharge.  Under  such  circum- 
stances, also,  the  pain  is  but  little  relieved  by  the  operation.     Again, 


HEMOKRIIOIDS.  131 

I  have  in  a  few  cases  seen  the  incision  heal  by  primary  intention  and 
the  sac  again  fill  with  blood,  thus  leaving  the  patient  in  the  same 
condition,  as  regards  soflering,  as  before  operation.  This  is  best 
avoided  by  placing  a  shred  of  lint  in  the  cut.  These,  however,  are 
untoward  accidents  which  may  attend  an  insignificant  operation 
which  usually  gives  relief  to  suffering,  and  allows  the  tumor  to 
shrivel  up  and  disappear  except  for  a  small  tag  of  skin  which  may 
remain  and  form  an  external  pile  of  the  second  variety. 

This  operation  is  so  trivial  and  the  relief  so  immediate  that  it  is 
generally  safe  to  perform  it  without  any  previous  explanation  to  the 
sufferer ;  but  should  it  not  be  permitted,  another  plan  must  be  fol- 
lowed. A  cathartic  containing  podophyllin  (pil.  podophyllin  co.) 
should  be  given  at  once  to  secure  two  or  three  free  actions  of  the 
bowels,  the  patient  put  upon  his  back  on  the  bed  or  sofa,  and  a  rub- 
ber ice  bag  filled  with  finely  powdered  ice  placed  against  the  part  and 
kept  there  till  the  pain  subsides.  Cold  usually  gives  great  and  im- 
mediate relief  ;  but  should  it  not,  a  poultice  may  be  substituted. 
Under  this  plan  of  treatment  the  yjatient  will  probably  be  relieved  in 
two  or  three  days,  so  as  to  be  able  to  get  around  with  comfort,  pro- 
vided the  clot  is  to  be  absorbed.  In  some  cases,  however,  suppura- 
tion will  occur,  and  in  about  a  week  from  the  time  the  swelling  first 
appeared  it  will  open  spontaneously  and  discharge  a  few  drops  of 
pus.  As  soon  as  it  becomes  evident  that  this  is  to  be  the  course  of 
events,  poultices  should  be  applied  and  continued. 

This  form  of  hemorrhoid  is  comparatively  trivial,  but  the  suffer- 
ing is  often  increased  by  improper  attempts  at  treatment.  Instead 
of  being  freely  cut,  they  are  often  punctured  with  a  needle  by  the 
patient.  The  result  is  the  escape  of  a  few  drops  of  bloody  serum,  re- 
lief for  an  hour  or  more,  and  then  renewed  suffering  from  the  bruis- 
ing and  squeezing  which  usually  attend  this  attempt  at  surgerj^  I 
have  seen  them  leeched  by  physicians,  with  the  result  of  starting  a 
slight  bleeding  which  continued  for  several  days,  without,  however, 
giving  any  relief.  They  are  not  infrequently  injected  with  carbolic 
acid  by  those  who  have  heard  of  this  method  of  treating  hemorrhoids, 
and  the  result  is  most  unsatisfactory,  for  the  pain  is  great  and  sup- 
puration almost  certain. 

Those  who  have  once  been  troubled  with  this  form  of  hemorrhoids 
are  very  liable  to  repeated  attacks.  The  veins  are  delicate  and  feebly 
supported,  and  a  little  unusual  strain  upon  them  is  sufficient  to  pro- 
duce an  extravasation.      The  preventive  treatment  of  this,   and  in 


132  SURGERY  OF  THE  RECTUM  AND  PELVIS. 

I'act  of  all  otiier  varieties,  consists  in  tlie  maintenance  of  as  perfect  a 
state  of  tile  general  health  as  possible,  perfect  regularitj^  in  the  ac- 
tion of  the  bowels  without  straining,  and  the  daily  use  of  cold-water 
ablutions  to  the  parts.  Tobacco  and  alcohol  must  both  be  used  in 
moderation,  if  at  all ;  over-eating  must  be  avoided  ;  and  if  a  careful 
regulation  of  the  diet  will  not  sufRce  to  produce  a  regular,  daily, 
natural  action  of  the  bowels,  a  slight  laxative  must  be  taken  daily. 
One  who  is  in  the  habit  of  having  a  passage  each  morning  may  easily 
bring  on  an  acute  ''attack  of  piles  "  in  a  few  hours  by  going  to  busi- 
ness without  taking  time  to  attend  to  this  function. 

In  another  form  of  external  hemorrhoid  the  vascular  element  is 
insignificant  as  compared  with  the  great  increase  in  connective  tissue 


Fig.  94. — External  Hemorrhoid  after  Injection  of  the  Vein. 

which  occurs.  This  tumor  seems  at  first  sight  to  be  only  skin  and 
connective  tissue,  and  is  often  improperly  spoken  of  as  a  condyloma, 
though  we  shall  reserve  that  term  for  an  entirely  different  condition. 

Such  a  tumor  may  result  directly  from  the  other  variety,  or  it 
may  gradually  form  as  the  result  of  the  irritation  of  more  serious 
disease  within  the  rectum  ;  under  the  latter  circumstances  being 
generally  due  to  the  contact  of  irritating  discharges  with  the  skin. 
When  the  first  variety  has  undergone  acute  inflammation,  a  tumor 
of  this  kind  is  the  natural  result ;  for  resolution  is  almost  never  com- 
plete. The  venous  tumor  becomes  harder  and  larger,  the  skin  over 
it  firmer,  it  loses  its  vascular  character  and  becomes  a  connective- 
tissue  tag  such  as  is  shown  in  Fig.  95. 

These  connective-tissue  growths  may  be  single  or  multiple,  and 
vary  in  size  from  a  pea  to  a  tumor  the  size  of  the  thumb.  The  anus 
may  be  so  completely  hidden  among  them  as  scarcely  to  be  discerni- 
ble. They  may  be  pendulous  or  attached  by  a  broad  base  partially 
encircling  the  anus.     They  are  often  excoriated  on  the  mucous  aspect, 


HEMORRHOIDS. 


133 


and  thus  give  rise  to  an  annoying  and  offensive  discharge.  At  the 
base  of  one  of  them  a  fissure  will  often  be  found,  and  it  has  some- 
times seemed  evident  to  me  that  the  latter  was  directly  due  to  the 
violence  resulting  from  the  weight  and  dragging  of  the  former. 

The  origin  of  these  tumors  should  be  well  understood.  When 
•found  at  the  anus  in  connection  with  a  stricture  of  the  rectum,  they 
have  been  supposed  to  indicate  syphilis  as  the  cause  of  the  stricture. 
I  have  no  faith  in  such  a  theory.  To  me  they  indicate  nothing  but  a 
continued  irritation  of  the  skin  of  the  anus.  They  are,  according  to 
my  experience,  as  frequent  in  cancerous  as  in  non-malignant  strict- 
ure, and  often  as  well  developed  when  there  is  no  serious  rectal  dis- 
ease. 

It  is  safe  to  say  that  the  surgeon  will  seldom  be  consulted  for 
these  tumors  alone  when  they  are  quiescent — that  is,  when  they 
are  not  acutely  inflamed  and  therefore  cause  no  pain.  But  they 
are  liable  to  become  inflamed  on  very  slight  provocation.  The 
same  causes  which  will  produce  the  last  variety  will  cause  acute 
inflammation  and  suppuration  in  this.     Then  the  patient  presents 


,r^^^>/, 


Fig.  95. — External  Cutaneous  Hemorrhoids, 


himself  with  much  the  same  symptoms  as  in  the  last  case,  except 
that  the  pain  has  been  more  protracted,  because  the  patient  is  more 
accustomed  to  the  annoyance  of  the  tumors  and  is  slower  to  seek  re- 
lief. An  examination  will  reveal  a  hard,  tender,  somewhat  osdema- 
tous  mass  of  tissue  just   at  the  verge  of  the  anus.      Its  attached 


134  sukgp:ky  of  the  rectum  and  pelvis. 

base  may  surround  nearly  one- third  of  the  anus  and  may  be  fully 
half  an  inch  thick.  It  cannot  be  forced  above  the  sphincter,  or,  at 
least,  cannot  be  made  to  remain  there.  There  may  be  two  or  three 
of  these  tumors.  The  outer  surface  is  composed  of  skin,  and  the 
inner  is  smooth  and  shining,  being  composed  in  part  of  finer  skin  and 


Fig.  96. — External  Hemorrhoid  with  Increase  of  Connective  Tissue. 

in  part  of  the  mucous  membrane  in  which  the  skin  ends  at  the  anus. 
It  is  plainly  a  connective-tissue  tumor,  having  its  attachment  outside 
of  the  rectum,  and  not  one  composed  of  blood-vessels  covered  by  the 
mucous  membrane  of  the  rectum. 

It  is  necessary  to  be  thus  particular  in  the  description  of  this 
form  of  hemorrhoid  because  of  the  painful  errors  often  seen  in  its 
treatment.  It  is  not  a  vascular  tumor,  and  therefore  the  leeching 
and  scarifications  often  resorted  to  never  give  any  relief,  while  the 
force  used  at  attempted  reductions  invariably  makes  matters  worse. 
If  allowed  to  take  its  own  course  it  will  seldom  suppurate,  but  will 
gradually  subside,  and  in  a  couple  of  weeks  the  pain  will,  in  great 
measure,  have  disappeared,  the  tumor  always,  however,  remaining 
somewhat  larger  than  before  the  attack. 

The  treatment  of  this  variety  is  essentially  the  same  as  in  the  last, 
although  the  cutting  to  be  done  is  more  considerable.  It  is  particu- 
larly in  this  class  of  cases  that  cocaine  may  be  used  to  the  best 
advantage.  If  the  base  of  the  tumor  be  small,  five  drops  of  a  four- 
per-cent.  solution  should  be  injected  into  it,  and  when  it  is  no  longer 
sensitive  it  may  be  seized  with  forceps  and  snipped  off  with  strong- 
scissors.  There  will  be  some  bleeding,  but  generally  only  a  little, 
and  styptic  cotton,  with  a  compress  and  bandage,  left  on  for  a  quarter 
of  an  hour  will  stop  it.  No  after-dressing  will  then  be  necessary  ex- 
cept cold  water,  or  possibly  a  poultice  to  relieve  pain.  If  the  tumor 
be  small,  the  patient  will  generally  be  free  from  pain  and  able  to 
attend  to  his  business  on  the  following  da}^  If  it  be  larger  it  is  better 
to  keep  him  in  bed  for  several  days,  with  cold  compresses  or  poultices 
to  the  wounds. 


HEMORRHOIDS.  135 

These  operations  are  best  performed  when  the  tumors  are  quiescent 
and  not  acutely  inflamed,  as  the  pain  will  then  be  much  less  and  the 
recovery  much  more  speedy.  But,  unfortunately  for  the  patient,  he 
seldom  wants  anything  done  till  he  has  had  a  good  deal  of  suffering, 
and  the  doctor  is  seldom  consulted  except  during  an  attack  of  in- 
flammation. Under  such  circumstances  nothing  is  gained  by  waiting 
for  the  attack  to  subside,  although  the  operator  must  allow  for  the 
infiltrated  condition  of  the  parts,  and  not  remove  enough  skin  to 
cause  subsequent  stricture. 

Supposing  now  that  the  patient  declines  operation,  the  case  must 
be  treated  as  follows :  Absolute  rest  in  bed,  laxatives  daily  to  keep 
the  bowels  free,  an  ointment  of  equal  parts  of  extract  of  opium  and 
extract  of  belladonna,  with  sufficient  vaseline  to  render  it  soft,  kept 
constantly  and  freely  smeared  over  the  parts,  and  hot  poultices  con- 
stantly applied.  By  this  means  the  inflammation  will  gradually 
subside,  and  in  an  ordinary  case  the  patient  will  be  around  in  a  week 
or  ten  days.  There  is  nothing  else  to  be  done.  Attempts  at  reduc- 
tion always  do  harm  and  can  by  no  possibility  do  good,  and  the  same 
applies  to  leeching,  scarification,  and  incision.  Should  suppuration 
occur  the  result  will  very  likely  be  a  subcutaneous  fistula. 

Internal  Hemorrhoids. — In  describing  these  tumors  it  is  only  nec- 
essary to  make  two  classes,  the  capillary  and  the  venous.  The 
capillary  hemorrhoid  is  in  reality  an  erectile  tumor,  composed  of 
the  terminal  branches  of  the  arteries  and  veins,  and  of  the  capillaries 
which  join  them.  This  form  of  tumor  is  never  of  large  size,  and 
never  projects  far  into  the  cavity  of  the  rectum.  To  the  naked  eye 
and  under  the  microscope  it  strongly  resembles  an  arterial  naevus. 
They  may  be  situated  high  up  in  the  rectum  or  low  down  by  the 
sphincter  ;  their  surface  is  granular,  and  the  membrane  covering  them 
is  always  of  extreme  thinness.  This  accounts  for  the  chief  symptom 
which  distinguishes  them  clinically  from  the  other  varieties — the  free 
hemorrhage  which  follows  the  slightest  bruising  of  their  surface,  even 
in  the  act  of  defecation.  Such  a  tumor  never  appears  outside  of  the 
anus  unless  accompanied  by  some  other  rectal  affection,  but  it  may 
sometimes  be  seen  by  a  careful  pulling  open  of  the  sphincter  with  the 
fingers,  and  from  some  part  of  its  strawberry-like  surface  there  is 
pretty  sure  to  be  a  jet  of  blood,  coming  j^er  saltum.  This  is  the  form 
of  hemorrhoid  to  which  the  name  of  "bleeding"  most  properly  ap- 
plies. In  my  own  experience  it  is  not  as  frequently  met  with  as  the 
varieties  to  be  described  later  ;  and  this  probably  for  the  reason  that* 


136  SUEGEEY    OF   THE   KECTUM    AND    PELVIS. 

after  existing  for  a  longer  or  shorter  period  in  this  form,  it  is  changed 
into  one  of  the  others,  and  that  patients  do  not  seek  relief  till  after 
such  change  has  occurred.  After  a  time  the  mucous  membrane  cov- 
ering such  a  tumor  becomes  thickened,  and  as  a  result  of  repeated 
irritation  there  is  an  increase  in  the  submucous  tissue.  The  hemor- 
rhage decreases  in  frequency,  and  finally  ceases  as  the  capillaries 
become  obliterated  by  the  increase  in  the  connective  tissue,  and  the 
capillary  tumor  is  succeeded  by  the  venous  one. 

The  one  symptom  of  a  capillary  hemorrhoid  is  the  daily  hemor- 
rhage ;  and  as  this  hemorrhage  occurs  at  the  time  of  defecation,  and 
there  is  no  pain  at  any  time,  the  patient  may  be  entirely  ignorant  of 
the  fact  that  blood  is  daily  lost.  This  is  particularly  the  case  with 
the  class  of  patients  seen  in  public  practice  who  give  little  attention 
to  themselves.  In  the  higher  walks  of  life  such  a  loss  of  blood  seldom 
occurs  without  the  knowledge  of  the  patient ;  but  unfortunately  it  is 
often  disregarded,  especially  in  women,  who  are  in  the  habit  of  losing 
blood  at  every  menstrual  turn,  and  who  always  shrink  from  an  ex- 
amination. 

It  is  not  necessary  to  relate  in  detail  the  train  of  constitutional 
symptoms  which  may  follow  the  daily  loss  of  a  considerable  quantity 
of  blood.  The  anaemic  look,  the  disturbance  of  the  heart's  action, 
the  troubles  with  the  digestive  apparatus  and  with  the  sexual  organs, 
the  cessation  of  menstruation,  are  all  well  known. 

This  is  the  only  form  of  hemorrhoid  in  which  applications  of 
nitric  acid  will  be  likely  to  result  in  permanent  cure,  and  in  this  it 
works  so  well  that  it  is  hardly  worth  while  to  try  other  things.  If 
the  application  be  made  thoroughly  to  the  whole  surface,  a  single 
one  will  be  all  that  is  necessary,  in  most  cases,  to  entirely  cure  the 
disease. 

The  only  other  cases  in  which  I  use  nitric  acid  are  those  of  well- 
marked  internal  hemorrhoids  which  bleed  freely  at  stool  when  pro- 
truded, and  in  which  for  any  reason — such,  for  example,  as  preg- 
nancy— it  is  inadvisable  to  attempt  a  radical  cure.  By  touching  the 
surface  of  these  tumors  with  strong  acid  the  bleeding  may  cease  en- 
tirely for  a  considerable  time,  and  the  tumors  may  even  diminish  in 
size. 

The  Venous  Hemorrhoid. — In  this  form  of  tumor  the  capillary 
network  has  disappeared,  and  in  its  place  is  found  a  mass  of  freely 
anastomosing  veins  bound  together  by  connective  tissue.  The  veins 
are  tortuous,  often  varicose  and  dilated  into  sacs  and  pouches  ;  and 


HEMORUHOIDS. 


137 


there  may  be  one  or  more  arteries  of  large  size,  tlie  pulsations  of 
wliicli  may  often  be  distinctly  felt  by  the  linger.  Such  a  tumor  is 
often  of  considerable  size.  Those  shown  in  Fig,  97  are  life-size.  They 
are  firm  to  the  touch  and  smooth  ;  liable  to  inflammation,  erosion, 


«55'^?     -  -17 


Fig.  97. — Internal  Hemorrhoids. 


hemorrhage,  and  prolapse.     The  hemorrhage  wiiich  occurs  is  arterial 
in  character  and  apt  to  be  abundant. 

Symptoms. — The  two  main  signs  of  internal  hemorrhoids  are  pro- 
trusion and  bleeding  ;  but  there  are  many  symptoms  less  diagnostic 
than  these,  but  of  fully  equal  importance.  For  example,  there  is  a 
peculiar  train  of  nervous  effects  which  is  quite  characteristic  of  the 
disease,  and  which  may  be  well  marked  before  either  bleeding  or 
protrusion  has  appeared.  These  are,  a  feeling  of  discomfort  in  the 
rectum  and  a  sensation  that  it  has  not  been  thoroughly  emptied  after 


188  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

stool,  which  induces  the  patient  to  sit  and  strain  for  a  long  time  ; 
difficulty  in  micturition  ;  diminished  sexual  power  and  desire  ;  pain 
in  the  genitals,  loins,  and  thighs  ;  and  formacation  in  the  lower  ex- 
tremities. A  very  marked  case  of  this  last  symptom  was  sent  to  me 
by  Dr.  Spitzka.  The  patient  was  himself  a  very  intelligent  phy- 
sician, who  had  consulted  Dr.  Spitzka  for  supposed  incipient  locomo- 
tor ataxia  ;  but  no  disease  of  the  spine  being  found,  he  was  referred 
to  me  for  rectal  examination,  under  the  suspicion  that  a  disease  of 
this  part  might  account  for  the  condition.  Such  was  found  to  be  the 
fact,  there  being  well  marked  hemorrhoidal  trouble  which  had  never 
manifested  itself  in  any  direct  way,  except  by  a  slight  uneasiness 
after  defecation,  and  the  cure  of  which  put  an  end  to  the  reflex 
symptoms. 

Pain  in  the  rectum  of  a  sharp,  lancinating  character  may  be  pres- 
ent as  an  early  symptom,  but  it  is  not  generally  complained  of  until 
the  tumor  begins  to  descend  within  the  grasp  of  the  sphincter  and 
appears  at  the  anus  at  each  act  of  defecation.  If  the  sphincter  be 
firm  and  strong,  it  is  then  apt  to  be  severe  and  the  tumor  may  be- 
come strangulated  ;  but  after  the  disease  has  existed  for  any  length 
of  time,  and  especially  in  persons  past  middle  life,  there  is  apt  to  be 
a  loss  of  power  in  the  muscle  which,  though  it  facilitates  prolapse, 
decreases  the  pain  attendant  upon  it. 

The  study  of  rectal  reflexes  is  a  very  interesting  one.  In  connec- 
tion with  hemorrhoids  I  have  seen  some  remarkable  nervous  phe- 
nomena. I  had  a  patient,  a  muscular  young  man,  who  was  nearly 
overcome  at  each  act  of  defecation  by  faintness.  There  was  no  pain, 
his  piles  were  of  moderate  size  and  easily  reducible,  but  every  time 
they  came  down  he  very  nearly  lost  consciousness. 

Another  symptom  of  rectal  disease  which  I  have  never  been  able 
to  understand  is  what  I  have  often  termed  proctophobia — the  sense 
of  impending  evil  which  is  so  common  in  rectal  troubles.  There  is 
hardly  any  variety  of  pain  or  of  functional  nervous  disease  that  may 
not  be  cured  by  the  simple  removal  of  hemorrhoids,  and  this  applies 
as  often  to  men  as  to  women. 

It  will  occasionally  happen  that  internal  hemorrhoids,  though 
fully  developed  and  of  many  years'  standing,  have  never  been  known 
by  the  patient  to  cause  any  loss  of  blood,  though  such  a  case  is  very 
rare. 

In  ordinary  cases  the  patient  will  reduce  the  tumors  when  they 
come  down  on  defecation.    They  may,  however^  become  strangulated 


HEMORUHOIDS.  139 

and  be  entirely  beyond  the  patient's  power  of  manipulation.  In  such 
a  case,  after  a  period  of  rest,  and  after  the  relief  which  may  follow 
a  spontaneous  escape  of  blood  from  the  overdistended  vessels, 
the  hemorrhoids  may  return  of  themselves  or  be  put  back  b}^  the 
patient. 

If  the  strangulation  be  more  intense,  gangrene  may  set  in  and  a 
part  of  the  mass  may  slough,  or  a  part  may  suppurate  and  pus  be 
discharged.  Under  these  circumstances  there  will  be  great  pain  and 
more  or  less  constitutional  disturbance,  with  fever  and  loss  of  appe- 
tite. The  gangrene  is  very  evident  to  the  eye  from  the  greenish  or 
blackish  color  and  fetid  odor  of  the  part,  and  is  rather  a  favorable 
termination  of  the  trouble,  as  it  generally  results  in  a  radical  cure. 

Diagnosis. — It  is  not  always  an  easy  matter  to  discover  an  in- 
ternal hemorrhoid,  even  though  it  be  far  enough  advanced  to  cause 
hemorrhage  and  more  or  less  uneasiness.  When  it  has  become  hard  it 
may  be  detected  by  the  accustomed  finger  in  a  simple  digital  exam- 
ination, but  when  soft  and  not  overdistended  it  may  escape  detec- 
tion. An  examination  should  be  made  directly  after  the  rectum  has 
been  emptied  by  an  enema  of  warm  water,  when  the  water  and  the 
straining  have  brought  it  into  prominence,  and  should  be  made  with 
a  speculum  when  there  is  any  doubt.  Under  these  circumstances  it 
may  generally  be  brought  into  view. 

The  existence  of  hemorrhoids  in  children  has  been  denied  by  ex- 
cellent observers  of  large  experience.  Gosselin  does  not  admit  the 
internal  variety,  and  says  plainly  that  he  will  believe  in  external 
hemorrhoids  in  children  when  he  has  seen  them,  or  when  a  good 
observer,  after  a  thorough  examination,  will  say  he  has  seen  them. 
It  may  be  safely  stated  that  internal  hemorrhoids  in  young  children 
are  exceeding  rare.  Of  the  external  variety  I  have  seen  one  per- 
fectly clear  case  in  a  child  of  three  years.  The  tumor  was  of  the 
external  venous  variety,  contained  a  large,  dilated  venous  pouch  in 
which  the  black  blood  could  be  distinctly  seen,  and  was  about  the 
size  of  an  ordinary  grape.  It  was  caused  by  the  straining  to  urinate, 
due  to  a  congenital  phimosis,  and  disappeared  spontaneously  with 
the  removal  of  the  cause.  My  case-book  at  the  New  York  Post- 
Graduate  Hospital  also  shows  one  case  of  well-marked,  prolapsing, 
internal  hemorrhoids,  operated  upon  with  clamp  and  cautery,  in  a 
child  about  three  years  old,  but  this  must  be  exceeding  rare. 

Treatment. — Before  recommending  anything  in  the  way  of  a 
surgical  operation,  the  surgeon  must  consider  whether  the  case  be- 


140  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

fore  liim  is  one  in  which  such  a  procedure  is  Justifiable ;  and  this 
brings  us  to  the  consideration  of  what  have  been  called  symptomatic 
hemorrhoids,  as  distinguished  from  those  which  are  apparently 
idiopathic. 

Internal  hemorrhoids  may  be  symptomatic  of  disease  in  a  num- 
ber of  the  viscera.  They  are  often  in  men  secondary  to  disease  of 
the  bladder,  to  enlarged  prostate,  or  to  stricture  of  the  urethra,  and 
in  these  cases  where  it  is  possible  to  remove  the  cause  it  must  always 
be  done.  If  hemorrhoids  are  dependent  upon  a  calculus  or  a  stric- 
ture of  the  urethra,  they  will  probably  disappear  when  these  affec- 
tions are  cured. 

In  women  hemorrhoids  often  depend  upon  disease  of  the  pelvic 
organs,  and  in  every  female  patient  this  dependence  should  be  care- 
fully inquired  into,  and,  if  found,  removed.  It  may  seem  strange  to 
say  that  I  have  cured  hemorrhoids  by  an  abdominal  hysterectomy  for 
fibroid  of  the  uterus  that  were  curable  in  no  other  way.  It  occasion- 
ally happens  that  a  pregnant  woman  will  suffer  so  severely  from  this 
complication  as  to  demand  surgical  aid.  Though  it  is  better  not  to 
operate  until  some  weeks  after  delivery,  except  in  a  case  where  the 
hemorrhage  or  the  pain  renders  it  unavoidable,  still  pregnancy  is  not 
an  absolute  barrier  to  surgical  interference  in  this  more  than  in  many 
other  affections,  though  the  liability  of  producing  miscarriage  should 
be  well  considered. 

Hemorrhoids  may  also  be  symptomatic  of  disease  of  the  liver, 
kidney,  heart,  or  lungs.  There  are  few  liver  affections  which  need 
prevent  operative  interference  in  a  bad  case,  but  such  interference 
should  be  preceded  by  general  treatment  pointing  toward  relief  of  the 
hepatic  circulation.  An  excess  of  alcohol  in  the  daily  diet  should  be' 
stopped,  and  a  blue  pill  may  be  given  with  advantage  every  other 
day  for  a  week  before  the  operation.  Affections  of  the  lungs,  except 
in  a  very  advanced  stage,  need  not  prevent  an  operation. 

Some  patients  will  deliberately  choose  a  course  of  palliative  treat- 
ment, even  knowing  that  it  is  not  curative,  rather  than  be  cured  by 
surgical  means.  For  such  the  practitioner  must  be  prepared  to  furn- 
ish what  relief  he  can,  and  this  is  often  very  great. 

It  is  sometimes  necessary  to  treat  a  patient  with  internal  hem- 
orrhoids for  the  complication  of  strangulation  when  he  is  unwilling 
to  submit  to  anything  looking  toward  radical  cure.  His  piles,  owing 
to  some  accident,  some  nervous  strain  or  irregularit,y  in  living,  are 
down,  have  been  down  a  day  or  two,  and  no  manipulation  on  his 


HEMORRHOIDS.  141 

part  will  put  tliem  back.  Examination  sliows  them  to  be  exquisitely- 
sensitive,  engorged,  and  possibly  even  gangrenous,  and  the  sphincter 
grasps  them  with  a  power  which  cannot  be  overcome.  This  extremity 
may  be  the  doctor's  opportunity,  and  many  a  patient  is  willing  to  be 
radically  cured,  after  forty-eight  hours  of  such  suffering,  who  has 
always  been  too  timid  before.  Under  such  circumstances  nothing  is 
to  be  feared  from  an  operation,  and  nothing  to  be  gained  by  delay. 
The  patient  should  be  etherized  and  the  tumors  removed.  The  cure 
will  be  as  rapid  as  under  ordinary  circumstances.  Should,  however, 
the  patient  still  object  to  radical  treatment,  the  following  is  the  best 
course  of  procedure  :  Place  her  on  her  left  side,  smear  the  whole 
mass  and  the  right  hand  freely  with  olive  oil,  cover  the  tumors  com- 
pletely with  the  fingers,  and  make  gentle  and  firm  pressure  on  the 
whole  mass  at  once  till  a  part  of  it  slips  up  the  bowel.  If  a  single 
tumor  will  give  place  the  others  will  soon  follow. 

This  is  not  a  matter  of  half  an  hour,  but  of  one  minute.  If  it  does 
not  succeed  at  the  first  attempt  it  probably  will  not  at  all ;  and  the 
next  step  is  to  give  ether  to  the  point  of  primary  anaesthesia  and 
forcibly  reduce  the  mass.  With  ether  internal  hemorrhoids  can 
always  be  reduced  when  strangulated  by  a  tight  sphincter.  Should 
the  patient  object  to  this,  there  is  .nothing  to  do  but  leave  her  in  bed 
with  ice  to  the  parts  and  the  ointment  of  opium  and  belladonna 
freely  applied.  The  tumors  may  slough  at  one  or  two  points  even 
without  the  ice,  and  the  ice  must  not  be  pushed  too  far  on  this 
account  ;  but  sloughing  under  these  circumstances  is  one  of  nature's 
means  toward  a  partial  cure.  Generally  after  a  couple  of  days'  rest 
in  bed  the  patient  will  be  able  to  reduce  the  tumors  for  herself. 

Though  it  is  difficult  to  conceive  of  a  case  of  hemorrhoids  that 
cannot  and  ought  not  to  be  cured,  where  the  patient  is  in  any  condi- 
tion to  bear  treatment,  there  are  some  which  can  only  be  cured  after 
prolonged  preparatory  treatment,  and  these  are  generally  in  women. 
The  doctor  who  does  much  rectal  practice  becomes  of  necessity  very 
familiar  with  many  of  the  diseases  of  women.  He  will  not  be  long 
in  practice  before  he  encounters  the  following  combination  :  A  lady 
comes  to  him  with  hemorrhoids,  upon  which  he  operates,  with  per- 
haps the  usual  good  result,  though  possibly  only  obtained  after 
rather  a  slow  and  painful  recovery.  In  the  course  of  a  few  months 
the  patient  returns  with  much  the  same  symptoms,  though  the  hem- 
orrhoids have  been  cured.  Another  examination  is  made,  and  the 
patient  is  found  to  have  an  enlarged  uterus  with  a  lacerated  cervix,  a, 


142 


SURGERY    OF   THE   RECTUM    AND    PELVIS. 


ruptured  or  greatly  relaxed  perineum,  and  a  proctocele,  or  perhaps  a 
uterine  fibroid,  all  of  which  should  have  been  cured  before  the  oper- 
ation for  hemorrhoids  was  attempted. 

Treatment. — Of  all  the  time-honored  operative  procedures  known 
to  the  profession  for  the  cure  of  hemorrhoids,  it  is  but  a  waste  of 


Fig.  yS. —  Operation  by  Ligature. 

time  to  discuss  at  the  present  day  more  than  a  few.     The  first  of 
these  is  the  ligature. 

The  principle  of  this  method  is  to  dissect  the  hemorrhoidal  tumor 
away  from  its  attachments  for  a  certain  extent,  and  then  to  surround 
the  remainder  of  the  base  with  a  ligature,  and  cut  away  the  tumor. 
The  advantage   of    this  method  is  that  the  ligature  is   not  placed 


HEMORRHOIDS.  143 

around  the  skin  at  the  margin  of  the  anus,  for  this  is  divided  with 
the  scissors  before  it  is  applied,  and  the  ligature  lies  in  the  groove 
thus  made,  and  by  this  means  much  pain  is  avoided  and  much 
time  is  saved  in  the  treatment. 

Regarding  the  details  of  the  operation  but  little  need  be  said. 
The  tumor  to  be  tied  is  seized  with  strong  forceps  and  drawn  down, 
the  patient  having  been  etherized  and  the  sphincter  previously 
dilated. 

With  strong  scissors  the  lower  attachments  of  the  tumor  all 
around,  and  especially  the  point  of  Junction  of  the  mucous  mem- 
brane with  the  skin,  are  divided  ;  the  ligature,  which  encircles  what 
remains,  is  tied  as  tightly  as  possible,  both  ends  are  cut  off  short, 
and  the  greater  part  of  the  tumor  below  the  ligature  is  also  cut  off, 
only  sufficient  being  left  to  form  a  good  and  safe  stump  for  the  liga- 
ture to  hold.  The  patient  is  prepared  for  the  operation  by  the  pre- 
vious administration  of  a  purgative,  and  the  bowels  are  confined  for 
a  week  or  so  after  its  performance,  and  then  relieved  by  a  cathartic. 

This,  in  brief,  is  the  operation  with  the  ligature,  and  it  is  an  ex- 
ceedingly good  one.  I  began  my  own  practice  by  always  performing 
it,  and,  did  I  not  believe  that  something  else  was  better,  should  per- 
form it  still.  It  is  as  safe  as  any  operation  can  well  be,  and  when 
properly  done  it  cannot  fail  to  cure  ;  and  perfect  safety  and  surety 
are  two  great  points  to  be  gained  in  any  operation 

But  a  considerable  experience  with  this  operation  led  me  after  a 
time  to  begin  the  search  for  something  just  as  safe  and  just  as  sure, 
without  some  of  the  objections  which  any  large  number  of  cases  will 
be  sure  to  show  pertain  to  this  method. 

The  first  objection  which  developed  itself  in  m}^  own  practice  was 
the  great  pain  which  the  patient  often  suffered  for  the  first  week  or 
ten  days.  It  is  distinctly  claimed  by  the  advocates  of  this  operation 
that  after  the  patient  has  recovered  from  the  ether  there  is  often  no 
pain.  I  can  only  say  that  though  this  is  sometimes  the  case,  it  is  by 
no  means  the  rule  in  my  own  practice  or  that  of  other  American  sur- 
geons. My  explanation  of  the  pain  I  have  often  seen  is  that  perhaps 
we  in  America  do  not  carry  the  dissection  as  far  up  as  it  may  be 
done,  rather  encircling  the  whole  mass,  except  the  skin,  in  the  liga- 
ture, than  dissecting  it  off  ;  and  that  consequently  a  cutaneous 
nerve  is  compressed  by  the  ligature  ;  but  no  matter  what  the  expla- 
nation, the  fact  remains  that,  having  followed  this  method  in  every 
particular,  I  have  more  than  once  been  forced  to  keep  the  patient 


144 


SURGERY    OF    THE    EECTUM    AND    PELVIS. 


constantly  under  the  influence  of  morphine  till  the  ligature  came 
away,  and  I  know  that  many  others  have  had  a  similar  experience, 

A  second  objection  is  the  frequent  necessity  for  the  passage  of  the 
catheter  for  several  days  after  the  operation. 

A  third  is  the  amount  of  blood  lost  during  the  operation,  and  the 
frequent  necessity  for  leaving  a  considerable  wad  of  lint  in  the  rectum 


\M 


Fig.  99. — Internal  Hemorrhoids,  showing  Line  of  Junction  of  the  Skin  and  Mucous  Membrane. 


on  account  of  the  ooziug,  which  causes  great  subsequent  suffering 
and  is  only  removable  after  three  or  four  days,  and  then  with  con- 
siderable pain. 

A  fourth  is  the  length  of  time  required  by  my  patients  before 
they  are  able  to  resume  active  business. 

It  will  be  seen  that  none  of  these  objections  were  of  vital  impor- 
tance. The  patients  still  recovered  and  were  radically  cured,  and  in 
the  end  were  satisfied  in  spite  of  these  difficulties  ;  but  still  there 
seemed  to  me  an  opportunity  for  a  more  satisfactory  operation. 

Treatment  hy  Injections. — As  far  as  my  own  influence  has  gone, 
I  have  done  what  I  could  to  take  this  method  of  treatment  from  the 
hands  of  the  quacks  and  place  it  upon  a  recognized  basis.  The 
fact  that  after  using  it  for  some  time  and  being  much  pleased  with 


HEMOKKHOIDS.  145 

it,  I  had  a  succession  of  bad  and  troublesome  cases  treated  by  this 
means,  and  that  these  cases  have  led  me  to  practically  abandon  the 
method,  in  no  way  invalidates  the  reports  of  my  own  carefully  ob- 
served cases  published  in  1886.  In  writing  now  I  shall  use  less 
glowing  terms  than  I  did  then.  It  is  still,  to  my  mind,  a  legitimate 
way  of  treating  some  cases,  having  in  certain  points  exceptional 
advantages  over  all  others  ;  and  in  the  fact  that  it  does  not  apply 
equally  well  to  all,  and  that  it  will  occasionally  be  followed  by  dis- 
agreeable consequences,  it  in  no  way  differs  from  other  surgical 
operations.  I  say  this  so  plainly  in  the  beginning  because  I  have 
so  frequently  been  accused  of  having  first  advocated  the  practice  and 
subsequently  abandoned  it,  which  is  perfectly  true.  It  is  now  at  a 
point  where  every  practitioner  may  try  it  for  himself  and  come  to  his 
own  conclusions  regarding  its  value.  All  that  can  be  said  of  my 
own  practice  is  that  while  for  a  year  or  more  I  used  it  almost 
exclusively  and  was  much  pleased  with  its  results,  a  succession  of 
bad  cases  has  led  me  decidedly  to  modify  my  views  of  its  valine  and 
universal  applicability. 

The  following  rules  should  be  observed  in  practicing  this  method  : 

The  solutions  of  carbolic  acid  should  be  in  pure  water  with 
sufficient  glycerin  added  to  make  ,a  perfectly  clear  and  colorless 
mixture. 

The  glycerin  and  carbolic  acid  should  both  be  perfectly  pure,  and 
as  soon  as  the  solution  begins  to  turn  yellowish  it  must  be  discarded. 

The  needles  should  be  fine  and  sharp,  and  the  syringe  in  perfect 
working  order — one  with  side  handles  is  preferable — and  before 
using  the  syringe  each  time  it  should  be  sterilized. 

Before  making  an  application  give  an  enema  of  hot  water,  and  let 
the  patient  strain  the  tumors  as  much  into  view  as  possible.  Then 
select  the  largest  and  deposit  five  drops  of  the  solution  as  near  the 
centre  of  the  tumor  as  possible,  taking  care  not  to  go  so  deep  as  to 
perforate  the  wall  of  the  rectum  and  inject  the  surrounding  cellular 
tissue.  The  needle  should  be  entered  at  the  most  prominent  point  of 
the  tumor.  If  the  hemorrhoid  does  not  protrude  from  the  anus,  a 
tenaculum  may  be  used  to  draw  it  into  view.  After  the  injection  has 
been  made  the  parts  should  be  replaced  and  the  patient  kept  under 
observation  for  a  few  minutes  to  see  that  there  is  no  unusual  pain. 
The  injection  will  cause  some  immediate  smarting  if  it  is  made  near 
the  verge  of  the  anus ;  if  made  above  the  external  sphincter,  the  pa- 
tient  may  not  feel  the  puncture  or  the  injection  for  several  minutes, 
10 


146  SUKGERY    OF   THE   RECTUM    AND   PELVIS.      • 

when  a  sense  of  pressure  and  smarting  will  be  appreciated.  In  some 
cases  no  pain  will  be  felt  for  half  an  hour,  but  then  there  will  be 
considerable  soreness,  subsiding  after  a  few  hours.  If  it  increases  in- 
stead of  disappearing,  and  if  on  the  following  day  there  is  considera- 
ble suffering,  which  may  not  perhaps  be  sufficient  to  keep  the  patient 
on  his  back,  but  is  still  enough  to  make  him  decidedly  uncomfortable, 
it  is  a  pretty  good  indication  that  a  slough  is  about  to  form.  For  the 
reason  that  it  is  impossible  to  tell  absolutely  what  the  effect  of  an 
injection  is  to  be  until  at  least  twenty-four  hours  have  passed,  it  is 
better  to  make  but  one  at  a  visit  and  to  wait  till  the  full  effect  of 
each  one  is  seen  before  making  another.  If  on  the  second  day  there 
is  no  pain  or  soreness,  another  tumor  may  be  attacked  ;  and  this  will 
often  be  the  case. 

The  objections  to  this  procedure  may  be  enumerated  in  the 
following  order :  pain,  ulceration,  marginal  abscess,  fistula.  The 
impossibility  of  giving  any  definite  prognosis  as  to  the  length  of  time 
necessary  to  effect  a  cure,  or  the  amount  of  suffering  the  treatment 
will  entail.  The  fact  that  the  treatment  does  not  result  in  a  radical 
cure,  but  that  the  tumors  reappear  generally  after  two  or  three  years. 

There  is  still  one  point  about  which  there  should  be  no  misunder- 
standing. From  all  the  information  attainable,  I  believe  that  my  ex- 
perience with  this  method  is  about  that  of  the  irregular  practitioners 
who  thrive  by  it,  and  that  the  proportion  of  cures,  without  any  pain 
or  bad  symptoms,  obtained  by  them  is  practically  the  same  as  my 
own.  I  have  certainly  tried  all  of  the  solutions  ordinarily  used  by 
them,  and  some  besides.  The  tincture  of  iron  and  the  fluid  extract 
of  ergot  are  two  from  which  I  hoped  for  better  results,  but  neither 
seemed  to  possess  any  advantages, 

I  believe  I  have  now  fairly  stated  the  advantages  and  disad- 
vantages of  this  plan  of  operating  upon  hemorrhoids,  and  have  put, 
as  far  as  my  own  experience  enables  me,  each  reader  in  position  to 
choose  for  himself  whether  he  will  use  it  or  not,  except  in  one  particu- 
lar. All  of  the  patients  I  had  supposed  cured  by  this  method,  and 
upon  whose  cases  I  based  my  former  favorable  report,  have  now 
returned  to  be  again  cured  by  some  more  lasting  method.  The 
relief  afforded  by  this  means  seems  to  last  about  two  years,  and 
I  find  none  of  my  patients  are  willing  to  submit  to  it  a  second  time. 

The  question,  in  fact,  narrows  itself  down  to  this  :  On  the  one 
hand  we  have  a  method  of  treatment  which  is  safe,  certain,  and 
practically  painless,  but  which  involves  the  administration  of  ether, 


HEMOKRHOIDS.  147 

the  performance  of  what  the  patient  dreads,  a  surgical  operation,  and 
a  certain  confinement  to  the  house  for  a  few  days.  On  the  other 
hand  we  have  a  method  which  avoids  the  ether,  the  surgical  opera- 
tion, and  perhaps  the  confinement  to  the  house,  but  which,  in  fact, 
involves  a  more  serious  operation  than  the  other,  only  more  quickly 
performed,  and  which  is  neither  radical  nor  certain  in  its  results,  and 
always  liable  to  be  followed  by  serious  complications. 

As  regards  the  comparative  suffering  caused  by  the  two  opera- 
tions, the  clamp  or  the  ligature  as  compared  with  the  injections,  it 
may  be  taken  for  a  fact  that  any  considerable  number  of  cases  will 
show  greater  pain  spread  over  a  longer  time  with  the  latter  than  with 
the  former  ;  and  all  the  patient  actually  gains  in  the  most  favorable 
case  is  the  avoidance  of  a  safe  operation  which  he  fears,  while  he  sub- 
mits to  an  uncertain  one  which  he  does  not  fear  because  of  his  igno- 
rance. 

Should  the  surgeon  decide  to  employ  this  method,  the  following 
points  may  not  be  iiseless  :  Use  the  weaker  solutions  in  preference 
to  the  stronger.  Never  use  it  in  any  of  the  forms  of  external  tumors. 
In  cases  of  large,  prolapsing,  and  long-standing  disease,  expect  pain 
and  perhaps  marginal  abscesses.  Be  very  cautious  in  prognosis  as  to 
the  time  the  treatment  will  require  and  the  amount  of  pain  it  will 
cause.  In  fact,  it  will  generally  be  safer  to  acknowledge  the  uncer- 
tainty as  to  these  two  important  points  of  the  operation. 

The  Clamp  and  Cautery. — The  operation  with  the  clamp  is  gener- 
ally known  as  that  of  Mr.  Henry  Smith,  of  London,  and  to  him  it 
owes  its  general  introduction  and  acceptance  by  the  profession,  though 
he  claims  no  originality  in  the  method  itself,  but  only  in  some  of  its 
details. 

The  essential  idea  of  this  operation  is  to  seize  the  part  to  be  re- 
moved, apply  the  clamp  to  its  base  as  a  temporary  hemostatic,  cut 
it  off  with  scissors,  and  cauterize  the  stump.  The  clamp  acts  merely 
as  a  temporary  ligature  to  prevent  bleeding  during  the  operation, 
and  the  cautery  is  to  prevent  bleeding  after  the  clamp  has  been  re- 
moved. The  instruments  which  are  indispensable  are  therefore  four 
in  number — a  double  tenaculum  forceps  to  seize  the  pile,  shown  in 
Fig.  100,  the  clamp  shown  in  Fig.  101,  scissors,  and  the  cautery. 

The  clamp  is  a  modification  of  Mr.  Smith's,  which  I  have  had 
made  for  my  own  convenience,  and  the  difference  can  be  seen  at  a 
glance.  Mr.  Smith' s  instrument  (Fig.  102)  is  armed  with  ivory  shields 
to  prevent  the  possible  effects  of  radiated  heat  ;  it  has  scissors  han- 


148 


SURGERY    OF   THE   RECTUM   AND   PELVIS. 


dies,  and  the  edges  of  the  blades  are  smooth.  In  my  own  there  are 
no  shields,  and  the  handles  are  much  larger.  I  was  led  to  abandon 
the  ivory  shields  because  I  found  them  practically  unnecessary  and 


Fig.  100. 


because  they  made  the  instrument  more  cumbersome.  The  handles 
were  modified  to  give  increased  power  and  to  avoid  the  general  use 
of  the  screw  for  closing  the  blades.  The  edges  were  at  first  serrated 
to  add  to  the  crushing  force,  but  experience  has  convinced  me  that 


Fig.  101. — Author's  Clamp. 


even  with  this  amount  of  power  the  clamp  is  incapable  of  crushing 
the  tissues  to  any  extent,  and  I  have  discarded  the  serration  for  anti- 
septic reasons.  I  have  placed  it  on  a  tumor,  screwed  it  up  to  its 
greatest  possible  power,  and  left  it  in  this  condition  for  fifteen  niin- 


FlG.  103. — Smith's  Clamp. 


utes.  While  it  was  in  position  the  hemorrhoid  became  cold  and 
livid,  but  when  the  pressure  was  removed  the  vessels  immediately 
filled  up  and  the  circulation  was  restored.  It  is  for  this  reason  that 
I  say  the  clamp  acts  merely  as  a  provisional  ligature  during  the  oper- 
ation.    In  fact,  no  force  capable,  of  crushing  the  tissues  to  the  point 


HEMOUIlIKtIDS.  149 

of  causing  the  occlusion  of  the  vessels  and  tlie  death  of  the  parts  can 
be  exercised  without  much  greater  mechanical  powder  than  this  clamp 
possesses.  There  can  be  no  bleeding  while  the  clamp  is  in  position  if 
the  handles  are  lirmly  closed  with  one  hand  ;  but  unless  the  cut  sur- 
face has  been  thoroughly  cauterized,  there  will  be  immediate  bleed- 
ing on  its  removal.  The  advantage  of  the  form  of  handle  shown  in 
my  instrument  over  that  of  Mr.  Smith  is  that  an  adequate  pressure 
can  be  kept  up  for  any  length  of  time  without  the  intervention  of  the 
screw,  and  by  this  fact  the  length  of  time  consumed  in  operating  is 
much  diminished. 

The  cautery  is  the  most  important  of  all  the  instruments,  being 
the  most  delicate. 

Very  little  preparation  for  this  operation  will  be  found  necessary 
in  a  healthy  patient.  When  one  in  good  health  tells  me  his  bowels 
are  acting  regularly  I  have  about  abandoned  the  time-honored  custom 
of  deranging  their  action  with  a  purgative  just  previous  to  this  oper- 
ation ;  and  if  they  have  moved  on  the  morning  of  the  operation,  all 
that  is  necessary  is  a  simple  enema  of  warm  water  an  hour  before  the 
operation  begins.  If  given  an  hour  before,  it  will  generally  all  be 
passed  before  the  arrival  of  the  surgeon.  If  given  after  the  arri- 
val of  the  operator  he  stands  a  good  chance  of  receiving  a  large 
portion  of  it  in  his  lap  and  on  his  towels  the  moment  he  dilates  the 
sphincter. 

The  operation  is  performed  in  the  following  manner  : 

As  a  rule  the  patient  is  etherized,  in  order  to  permit  a  free  dilata- 
tion of  the  sphincters.  The  tumors  are  next  seized  and  removed  one  by 
one.  No  speculum  is  necessary  for  this,  but  if  one  be  used  the  large 
Sims  rectal  speculum  is  the  best.  The  tumor  is  seized  with  the  for- 
ceps and  held  out  of  the  anus,  while  the  base  at  the  juncture  of  the 
skin  and  mucous  membrane  is  divided  as  in  the  ligature  operation, 
and  the  clamp  applied  to  what  remains  of  the  pedicle  in  the  sulcus 
thus  made.  The  forceps  are  next  detached,  the  tumor  cut  off  with 
the  scissors  (but  not  so  short  but  that  a  good,  firm  stump  remajns), 
and  the  cautery  is  then  taken  from  the  assistant,  whose  sole  duty  it 
should  be  to  have  it  always  ready,  and  applied  thoroughly  to  the 
stump  of  the  hemorrhoid.  No  haste  should  be  used  in  this  step  of 
the  operation.  The  pedicle  should  be  thoroughly  charred  with  the 
platinum  at  a  red  heat. 

When  this  has  been  done  the  clamp  may  be  loosened,  without 
being  removed,  to  see  if  any  vessel  in  its  grasp  is  still  inclined   to 


150  SURGERY  OF  THE  RECTUM  AND  PELVIS. 

bleed  ;  and  if  a  bleeding  point  appear,  it  is  again  tightened  and 
the  cautery  is  again  applied.  Thirty  seconds  is  an  abundance  of 
time  for  each  tumor.  The  secret  of  success  in  this  operation  is 
found  just  here.  If  all  the  cut  surface  is  thoroughly  cauterized 
while  the  clamp  is  on,  there  can  be  no  hemorrhage ;  but  if  more 
surface  is  cut  than  is  cauterized,  hemorrhage  may  reasonably  be 
expected  and  the  operator  is  to  blame.  Thoroughly  cauterize  the 
entire  incision,  except  the  initial  one  made  before  the  clamp  is  ap- 
plied, and  trust  nothing  to  the  clamp  or  to  nature  is  the  advice  I 
always  try  to  impress  most  strongly  on  those  studying  this  oper- 
ation. 

When  all  the  piles  have  been  removed,  the  stumps  will  naturally 
retract  within  the  sphincter  and  no  dressing  will  be  necessary. 

The  thing  most  difficult  for  the  unpractised  operator  to  under- 
stand is  at  just  what  point  to  apply  the  clamp  ;  and  this  can  best  be 
learned  by  experience,  as  it  really  constitutes  the  delicate  point  in 
the  operation.  There  is  no  difficulty  when  the  tumor  is  an  internal 
one  arising  fairly  from  the  mucous  membrane  above  the  sphincter, 
and  not  involving  the  skin  of  the  anus.  In  such  a  case  the  clamp 
does  not  implicate  the  muco-cutaneous  junction  at  the  anus,  and 
removing  too  little  tissue  will  not  leave  unsightly  and  annoying 
tags  of  skin,  nor  will  removing  more  than  is  necessary  result  in 
cicatricial  contraction  to  a  serious  extent.  But  where  the  margin  of 
the  anus  tends  to  roll  over,  as  is  shown  in  Fig.  99,  considerable  ex- 
perience is  necessary  to  learn  just  how  much  tissue  to  include  in  the 
clamp. 

When  it  is  necessary  to  divide  the  skin  of  the  anus  with  the  scis- 
sors before  applying  the  clamp,  there  will  be  a  little  bleeding,  which 
is  easily  stopped  by  a  compress  and  bandage  ;  but  when  the  clamp 
is  applied  only  to  parts  covered  by  mucous  membrane,  and  used 
without  any  preparatory  cutting,  the  operation  is  almost  bloodless, 
and  under  any  circumstances  it  is  unnecessary  to  soil  more  than  a 
single  towel.  This  is  a  great  desideratum  in  cases  of  enfeebled 
patients,  besides  enabling  the  operator  to  have  his  wounds  perfectly 
dry  without  the  use  of  any  lint  or  other  dressing. 

No  dressing  of  any  sort  is  necessary  after  the  clamp  operation, 
except  a  pad  of  gauze  covered  with  vaseline,  and  a  T-bandage  ap- 
plied for  a  few  minutes  to  arrest  oozing  from  the  preliminary  in- 
cisions in  the  skin.  If  the  patient  seems  to  be  doing  well  and 
complains  of  no  untoward  symptoms,  the  parts  need  not  be  ex- 


HEMORRHOIDS.  151 

amined  for  ten  days,  and  all  that  is  required  is  cleanliness  to  the 
wound. 

The  bowels  should  be  confined  for  forty-eight  hours,  and  about 
thirty-six  hours  after  the  operation — in  other  w^ords,  at  night  of  the 
following  day — they  should  be  encouraged  to  act  by  a  slight  laxative, 
either  a  pill  or  a  saline.  A  single  dose  will  generally  be  sufficient, 
and  when  the  time  comes  for  the  bowels  to  move,  an  enema  of  water 
should  be  thrown  up  the  rectum  to  facilitate  the  passage.  In  this 
way  an  almost  complete  clearing  out  of  the  rectum  is  secured  on  the 
second  day.  The  patient  dreads  this  first  motion,  but  is  agreeably 
disappointed,  often  being  surprised  that  he  has  much  less  pain  than 
liis  hemorrhoids  caused  him  in  each  passage  before  they  were  re- 
moved. 

The  bowels  may  be  treated  in  this  way  after  the  ligature  opera- 
tion with  great  advantage. 

I  do  not  wish  to  convey  the  idea  that  no  pain  follows  this  opera- 
tion, but  I  can  honestly  say  that  many  patients  have  less  pain  on 
the  day  following  it  than  they  have  suffered  daily  from  their  hemor- 
rhoids for  years  before.  I  usually  expect  some  of  that  annoying 
spasm  of  the  levator  which  no  stretching  of  the  sphincter  can  pre- 
vent ;  and  when  this  is  present  it  will  begin  a  few  hours  after  the 
ether,  and  may  last  for  the  following  day  or  two  ;  but  it  is  not 
generally  sufficient  to  prevent  a  good  night's  sleep,  and  it  is  often 
so  slight  as  to  cause  no  comment  by  the  patient.  It  is  very  excep- 
tional for  any  anodyne  to  be  necessary,  even  on  the  first  night  after 
operating.  Even  this  spasmodic  contraction  of  the  muscle  is  not 
always  present. 

The  length  of  time  the  patients  are  confined  to  the  house  of 
course  varies.  They  are  generally  sitting  up  on  the  second  day, 
or  at  most  the  third,  and  walking  around  the  room  tending  to  their 
own  wants  ;  the  men  smoking  and  reading,  the  women  receiving 
visits  or  sewing  ;  and  one  of  the  details  about  which  the  physician 
needs  to  be  most  strict  is  to  keep  the  patient  quiet  in  the  house  until 
the  healing  has  so  far  advanced  as  to  make  active  exercise  safe. 
Many  of  my  own  cases  come  from  a  considerable  distance,  and  are 
anxious  to  return  to  their  own  homes  as  soon  as  possible.  I  usually 
aim  to  secure  at  least  ten  days,  but  I  find  they  are  very  apt  to  depart 
at  the  end  of  a  week,  and  occasionally  five  days  sees  them  on  their 
Journe3^ 

I  do  not  mean  that  this  should  be  encouraged  or  recommended, 


152 


SUKGERY   OF   THE   RECTUM   AND   PELVIS. 


for  it  is  very  mucli  better  that  the  patient  should  remain  quies- 
cent until  the  wounds  are  well  advanced  toward  cicatrization ;  but 
it  shows  better  than  anything  else  the  general  condition  of  the 
patient  when  there  is  no  suffering  which  induces  him  to  wish  to  stay 
in  his  room. 


The  Operation  of  Excision^  or  WTiiteliead' s  Operation. 

This  consists  in  amputating  the  entire  "pile-bearing"  region  oL' 
mucous  membrane.  An  incision  is  made  around  the  anus  at  the 
junction  of  the  skin  with  the  mucous  membrane  ;  the  latter,  with 
the  hemorrhoidal  tumors,  is  dissected  upward  till  the  upper  limit 
of  the  hemorrhoids  is  passed,  and  then  amputated  by  a  circular  inci- 
sion. The  mucous  membrane  is  then  drawn  down  from  above  and 
stitched  to  the  skin.    Various  modifications  have  been  made  in  the 


^ 


'4 


Fig.  103.— Operation  by  Excision.     1,   Hemorrhoid  ;   2,  incision  ;   3,  junction  of  skin  and  mucous 

membrane. 


technique,  all  intended  to  facilitate  the  performance  of  a  naturally 
unnecessarily  tedious  operation  ;  but  no  essential  change  has  been 
made  in  the  guiding  principle. 

This  operation  is  based  by  its  advocates  upon  the  proposition 
that  neither  the  ligature  nor  the  cauterj^  are  radical  operations,  be- 
cause they  only  remove  the  hemorrhoids  and  do  not  remove  all  of 


HEMORRHOIDS.  153 

the  "pile-bearing  area" — a  proposition  which  I  believe  to  be  abso- 
lutely untenable  either  in  theory  or  as  shown  by  clinical  experience. 
There  are,  moreover,  two  serious  practical  objections  to  this  method 
of  operating. 

The  success  of  the  operation  depends  entirely  upon  securing 
union  of  the  adapted  surfaces  by  first  intention.  Failure  in  this 
means  bad  stricture  of  the  rectum  ;  and  failure  to  get  union  b}^  first 
intention  is  nowhere  more  common  than  in  this  part  of  the  body.  A 
sufficient  number  of  these  cases  are  now  on  record  in  the  practice  of 
the  best  hospital  surgeons  in  'New  York  to  render  this  operation  one 
of  doubtful  propriety  while  we  have  so  many  more  reliable  ones  as 
we  now  possess.  It  is  true  that  stricture  may  follow  either  the 
ligature  or  the  clamp,  but  in  the  nature  of  these  operations,  consist- 
ing, as  they  do,  in  the  removal  of  successive  segments  of  mucous 
membrane,  sufficient  strips  of  normal  tissue  are  almost  always  left  to 
prevent  this  accident,  and  a  good  operator  will  take  especial  pains  to 
preserve  enough  mucous  membrane  to  prevent  closure  of  the  anus 
by  cicatrization.  In  Whitehead's  operation  the  whole  mucous  mem- 
brane is  dissected  up  and  amputated,  more  being  brought  down  from 
above  to  take  its  place.  If  this  holds,  all  is  well ;  if  it  fails  to  unite 
by  first  intention,  there  is  a  wide  ulcer  completely  surrounding  the 
anus,  and  a  stricture  is  the  necessary  consequence.  The  slight  strict- 
ure which  may  result  from  either  the  ligature  or  clamp  operation  is 
easily  curable  by  suitable  treatment.  This  one  is  not,  and  in  one 
case  I  have  been  forced  to  do  a  complete  extirpation  of  the  rectum 
for  such  stricture  and  ulceration  in  a  case  operated  upon  in  one  of 
our  large  New  York  Hospitals. 

I  have  also  recently  seen  several  cases  which  illustrate  another 
danger  of  this  method,  and  one  which  I  had  not  thought  likely  to 
occur.  The  patients  have  all  been  operated  upon  by  hospital  sur- 
geons, and  in  all  the  anus  now  presents  a  peculiar  appearance,  at 
first  sight  resembling  a  slight  but  complete  prolapse.  The  incision 
in  the  operation  had  been  outside  the  muco-cutaneous  injection  ;  the 
mucous  membrane  had  been  drawn  down  to  meet  it  and  had  united 
by  first  intention.  Result :  a  ring  of  excoriated  mucous  mem- 
brane, in  half  of  its  extent  fully  an  inch  wide,  surrounding  the 
entire  circumference  of  the  anus,  and  ending,  without  any  shad- 
ing off,  but  suddenly  and  abruptly,  in  health}^  skin.  The  condi- 
tion is  an  exceedingly  annoying  and  troublesome  one  and  can 
only  be  relieved  by  fresh  surgery.     I  have  now  the  notes  of  several 


154  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

such  cases  which  have  applied  to  me  for  relief  after  submitting  to 
this  procedure. 

On  the  whole,  it  may  be  said  that  the  operation,  though  more 
diflBcult  of  performance  than  either  the  clamp  or  the  ligature,  yields 
excellent  results  in  skilled  hands,  but  is  liable  to  be  followed  by  very 
annoying  after-consequences  in  the  hands  of  those  less  experienced. 
In  time  of  convalescence,  after  pain  and  reflex  disturbance,  and  cer- 
tainly of  cure,  it  has  no  advantages  over  the  others  described. 


CHAPTER   X. 


PROLAPSE. 


Or  prolapse  of  the  rectum  there  are  two  distinct  varieties. 


Prolapse  of  the  Mucous  Membrane  Alone. 

This,  which  is  sometimes  spoken  of  as  "partial"  prolapse, 
because  only  a  part  of  the  wall  of  the  rectum  is  involved  in  the 
descent,  is  well  represented  in  Fig.  104 


Prolapse  of  all   the  Coats  of  the   Rectum^  including^  when   the 
disease  is  of  sufficient  extent,  the  Peritoneum  (Fig.  105). 

The  first  form  is  a  mere  everting  of  the  mucous  membrane  of  the 
lowest  portion  of  the  rectum,  rendered  possible  by  the  laxity  of 
the  submucous  connective  tissue.  It  is  seen  as  an  accompaniment 
of  old  cases  of  hemorrhoids,  and  its  mechanism  may  be  studied  at 
any  time  upon  the  horse,  in  which  it  occurs  naturally  at  the  close  of 
each  act  of  defecation. 

The  second  variety  is  an  exaggeration  of  the  first,  in  which,  after 
the  submucous  connective  tissue  has  yielded  to  its  utmost,  the  whole 
thickness  of  the  rectum  begins  to  descend,  and  finally  protrudes.  It 
follows,  of  necessity,  that  after  this  protrusion  has  reached  a  certain 
length  the  peritoneal  coat  must  also  descend  outside  of  the  body, 
and  this  condition  is  shown  at  a  glance  by  reference  to  the  plate.  In 
both  of  these  forms  the  protrusion  begins  first  at  the  part  of  the 
rectum  nearest  the  anus. 


156 


SURGERY    OF   THE    RECTUM    AIs'D    PELVIS. 


Prolapse  of  the  Mucous  Membrane  Alone. 

This  is  perhaps  the  most  common  variety  of  the  disease.  It  is 
found  in  children  most  often  between  the  years  of  two  and  four, 
and  in  adults  it  is  more  frequent  in  women  than  in  men.  Its  causes 
are  various.  Among  them  may  be  enumerated  the  following  :  Those 
which  tend  mechanically  to  draw  down  the  mucous  membrane,  such 
as  hemorrhoids,  polypi,  vegetations,  and  tumors.     Those  which  tend 


Fig.  104. 
First  Form  of  Prolapse. 


to  weaken  or  to  destroy  the  action  of  the  sphincters,  such  as  ulcer- 
ations or  incisions.  Those  which  cause  muscular  spasm,  such  as  fis- 
sures, worms,  dysentery,  phimosis,  cystitis,  calculus,  stricture  of  the 
urethra,  and  enlarged  prostate.  Those  which  produce  permanent 
dilatation  and  weakening  of  the  sphincters,  such  as  spinal  paralysis 
and  traumatism.  To  this  lack  of  tonicity  of  the  sphincters  may  be 
attributed  the  frequent  occurrence  of  prolapse  in  feeble  and  badly 
nourished  children.  Those  which  produce  oedema  and  swelling  of 
the  pelvic  tissues,  such  as  pregnancy,  parturition,  fecal  accumula- 
tions, and  hepatic  lesions.  To  these  causes  it  may  be  proper  to 
add   one   anatomical   one  —  the    undeveloped    sacrum    in   children, 


PROLAPSE. 


157 


which,    by  its   straightness,   leaves  the  rectum   comparatively  un- 
supported. 

The  first  form  of  prolapse  generally  comes  on  gradually  and  sel- 
dom suddenly.  It  may  be  partial  or  complete  as  regards  the  circum- 
ference of  the  rectum,  being  in  some  cases  of  hemorrhoids  confined  to 
one  side  of  the  aperture,  and  in  others  involving  the  whole  circum- 
ference. It  presents  itself  as  a  scarlet  or  livid  mass  (depending  upon 
the  state  of  contraction  of  the  sphincter)  projecting  from  the  anus, 
covered  with  the  natural  secretion  of  the  bowel,  directly  continuous 
with  the  skin  on  one  side  and  with  the  mucous  membrane  on  the 
other,  and  arranged  in  folds  which  radiate  from  the  central  aperture 
toward  the  circumference.  It  is  at  first  spontaneously  reducible,  or 
at  least  easily  replaced  by  a  slight  pressure,  and  remains  reduced  till 
the  next  act  of  defecation  ;  but  as  the  amount  of  prolapsed  membrane 
increases,  the  difficulty  in  reduction  becomes  greater.  At  first,  also, 
there  is  no  pain,  but  after  a  time  the  act  of  defecation  comes  to  be 


Fig.  105. 
Second  Form  of  Prolapse. 


greatly  dreaded  by  the  patient,  and  the  suffering  continues  till  the 
tissue  is  replaced. 

As  already  said,  the  second  variety  of  prolapse  differs  from  the 
first  in  the  fact  that  it  is  composed  of  the  whole  thickness  of  the 
bowel,  and,  therefore,  when  of  suflacient  length,  of  peritoneum  also. 


158 


SUEGERY    OF   THE   RECTUM   AND   PELVIS. 


It  is  probable  that  every  prolapse  of  more  than  two  inches  in 
length  may  contain  peritoneum  ;  and  it  follows  from  the  anatomy 
of  the  parts  that  the  peritoneum  will  extend  lower  on  the  front  than 
behind.  In  the  peritoneal  pouch  thus  formed  there  may  be  located 
coils  of  intestine,  an  ovary,  or  a  part  of  the  bladder.  In  this  form 
of  prolapse  there  is  no  groove  or  sulcus,  and  the  absence  of  such  a 
groove  is,  therefore,  no  proof  of  the  non-existence  of  a  fold  of  peri- 
toneum in  the  tumor. 

It  is  a  mistake  to  suppose  that  this  second  variety  is  not  met  with 
in  children,  for  it  is  only  an  exaggerated  form  of  the  first,  being  the 
next  step  in  the  descent  after  the  submucous  connective  tissue  has 
yielded  its  utmost ;  and  exaggerated  cases  of  prolapse  are  often  seen 


Fig.  106. 
Prolapse. 


in  children.  It  is  distinguished  from  the  first  variety,  first  of  all,  by 
its  size  (Fig.  106).  The  first  is  never  very  large  ;  while  the  second, 
from  the  nature  of  the  case,  must  be  of  considerable  dimensions. 
Again,  a  prolapse  of  the  second  variety  is  generally  of  long  standing. 
The  second  generally  follows  the  first,  but  a  prolapse  may  be  of  this 
variety  from  the  beginning,  resulting,  in  such  a  case,  generally  from 
violent  straining,  and  coming  on  suddenly.  The  first  variety  is  not 
firm  and  thick  to  the  feel  ;  the  folds  of  mucous  membrane  radiate 
from  the  orifice  to  the  circumference,  and  the  opening  is  circular  and 
patulous.  In  the  second  the  orifice  is  slit-like  and  is  drawn  backward 
by  the  attachment  of  the  meso-rectum,  or,  in  females,  forward  by  the 
closer  attachment  to  the  vagina.      The  form  of  the  tumor  is  conical, 


PKOLAPSE.  159 

its  walls  are  thick  and  firm,  and  wlien  pressed  between  the  fingers  the 
gurgling  of  gas  in  a  contained  loop  of  intestine  may  sometimes  be 
detected,  and  a  resonance  may  be  obtained  on  percussion. 

If  such  a  tumor  be  carefully  dissected,  the  coats  of  the  protruded 
bowel  will  be  found  enlarged,  the  mucous  membrane  will  be  seen  to 
be  thickened  and  dense  in  structure,  especially  at  the  free  extremity, 
and  it  will  also  sometimes  be  found  eroded  and  granular.  The  sub- 
mucous areolar  tissue  will  be  seen  to  be  infiltrated,  and  the  muscular 
layers  hypertrophied.  Owing  to  these  changes  the  bowel  is  actually 
increased  in  size  and  becomes  too  large  to  be  retained  in  its  proper 
place,  which  explains  the  difficulty  often  experienced  in  reducing  it 
and  in  keeping  it  reduced,  in  spite  of  the  constant  straining  and  de- 
sire for  defecation,  which  it  produces.  These  changes  in  the  mucous 
membrane  may  in  rare  cases  result  in  the  production  of  a  foul,  hard, 
bleeding,  eroded  mass. 

The  causes  of  the  second  variety  are  the  same  as  of  the  first,  and 
need  not  again  be  enumerated.  The  symptoms  also  are  the  same, 
with  the  addition  of  more  or  less  incontinence  of  faeces  in  old  cases  ; 
but  the  treatment  is  not  the  same  in  all  respects,  for  certain  measures 
which  may  be  safe  when  a  prolapse  contains  no  peritoneum  may  be 
fatal  under  the  opposite  condition. 

A  prolapse  is  apt  to  increase  slowly  in  size  as  time  advances.  In 
children  especially,  it  may  at  first  cause  little  apparent  discomfort. 
The  bowel  is  usually  replaced  by  the  parent  after  defecation,  and  the 
condition  is  well  borne  till  more  or  less  inflammation  and  erosion  of 
the  parts  set  in.  Then  each  act  of  defecation  is  greatly  feared. 
After  a  time  the  protrusion  becomes  more  frequent  and  remains  down 
longer,  till  finally  it  is  down  most  of  the  time.  Then  suddenly  a 
change  occurs  and  replacement  is  no  longer  possible.  This  will 
bring  the  case  to  the  surgeon,  and  he  will  find  all  the  difficulties  in- 
creased four-fold  by  the  existence  of  one  of  two  conditions — inflam- 
mation or  strangulation. 

When  inflammation  has  occurred  there  will  be  more  or  less  febrile 
action  and  constitutional  disturbance.  The  prolapse  will  be  swollen, 
hard,  and  painful  if  the  inflammation  is  in  progress  ;  if  it  has  passed 
off,  the  tumor  will  be  left  larger  and  harder  than  before,  from  infil- 
tration.    The  mucous   membrane   will  be   thickened,   and   may   be 


160  SURGERY   OF   THE   RECTUM    AND   PELVIS. 

eroded  or  ulcerated,  and  tlie  difficulty  of  reduction  is  greatly  in- 
creased from  the  changes  which  have  occurred  in  the  tumor.  Stran- 
gulation is  rare,  but  may  occur  where  the  tumor  is  large  and  the 
sphincter  firm.  It  may  be  temporary  when  properly  met,  or  it 
may  result  in  sloughing  which  shall  involve  a  whole  or  part  of  the 
tumor.  It  may  result  in  a  cure  by  sloughing,  or  it  may  extend  and 
cause  death  from  peritonitis.  When  the  sloughing  involves  the 
whole  prolapse  it  is  also  apt  to  cause  a  serious  stricture.  When  it 
involves  only  the  mucous  membrane  it  may  cause  just  sufficient  sub- 
sequent contraction  to  effect  a  cure.  These  changes  are  not  apt  to 
occur  in  the  first  form  of  the  disease,  and  are  generally  confined  to 
the  second  or  third. 

The  bleeding  from  a  prolapse  is  not  generally  a  very  important 
matter.  More  or  less  of  it  occurs  at  stool,  but  seldom  to  a  serious 
extent.  It  is  more  apt  to  be  a  general  oozing  than  a  free  hemor- 
rhage. 

It  would  seem  that  there  ought  to  be  little  difficulty  in  diagnos- 
ticating this  form  of  disease.  The  most  common  error  is  to  treat  a 
child  for  it  and  overlook  the  polypus  which  is  the  cause  of  it ;  but 
this  is  generally  the  result  of  prescribing  for  what  the  parents  call  a 
"coming-down  of  the  bowel,"  without  making  any  examination,  and 
can  hardly  be  called  diagnosis.  I  have  often  seen  large,  prolapsing 
internal  hemorrhoids  described  by  intelligent  physicians  as  prolap- 
sus, and  this  arises  from  a  failure  to  justly  appreciate  the  different 
nature  of  the  two  affections.  Both  are  protrusions  of  the  mucous 
membrane  from  the  anus,  it  is  true,  but  they  do  not  resemble  each 
other.  They  are  often  found  associated,  the  prolapse  being  second- 
ary to,  and  caused  by,  the  dragging  down  of  the  internal  hemor- 
rhoids ;  but  even  then  they  may  easily  be  distinguished  from  each 
other.  One  is  a  new  growth  composed  of  connective  tissue  and  blood- 
vessels, covered  by  mucous  membrane,  and  even  when  large  is  defin- 
itely and  plainly  circumscribed.  It  is  not  a  part  of  the  natural  rec- 
tum, but  an  adventitious  formation  which  may  be  removed,  leaving 
the  rectum  much  as  it  was  before.  Prolapse,  on  the  other  hand,  is  a 
part  of  the  rectum  itself  merely  displaced.  The  mucous  membrane 
is  not  changed ;  there  is  no  new  element  added  ;  it  is  not  a  circum- 
scribed tumor  or  collection  of  tumors,  but  a  more  or  less  voluminous 


PUOLAPSE.  161 

mass  of  the  rectal  wall.  They  resemble  each  other  very  little,  except 
that  they  are  both  covered  by  mucous  membrane. 

In  adults,  an  old,  eroded,  bleeding,  and  infiltrated  prolapse  may 
be  mistaken  for  malignant  growth,  and  I  have  seen  cases  in  which  the 
difference  could  only  be  made  out  by  most  careful  examination. 

But  by  far  the  most  important  point  for  the  practitioner  is  to  dis- 
tinguish one  form  of  prolapse  from  another,  and  particularly  this  one 
irom  the  ones  next  to  be  described.  Too  much  stress  cannot  be  laid 
upon  this  point,  for,  although  the  disease  is  not  at  all  an  uncommon 
one,  its  pathological  anatomy  does  not  seem  to  be  well  understood. 
To  the  minds  of  many,  one  prolapse  is  still  very  much  like  another, 
except  that  there  may  be  a  difference  in  size,  and  therefore  in  the 
amount  of  surface  to  be  cut  off  or  painted  with  nitric  acid  ;  and  until 
this  idea  is  thoroughly  eliminated  there  will  stiil  be  an  occasional 
€ase,  in  which  it  has  borne  its  fatal  fruit  in  the  way  of  treatment. 
When  it  once  begins  to  be  understood  that  putting  a  clamp  or  knife 
to  one  of  these  protrusions  may  involve  all  the  risks  which  would 
follow  the  ablation  of  an  inguinal  hernia,  a  great  advance  will  have 
been  made. 

It  will  generally  be  impossible  to  decide  by  physical  examination 
whether  a  prolapse  of  the  second  class  contains  peritoneum  or  not, 
unless  the  case  be  one  of  true  rectal  hernia  in  which  the  cul-de-sac 
of  peritoneum  contains  a  loop  of  small  intestine  or  some  of  the  pel- 
vic organs.  Such  cases  are  rare,  and  the  only  safe  rule  is  to  act  on 
the  supposition  that  every  prolapse  not  manifestly  of  the  first  variety 
may  contain  peritoneum,  and  act  accordingly. 


Rectal  Hernia. 

Under  its  proper  title  of  archocele,  or  rectal  hernia,  this  affection 
is  seldom  found  described,  and  this  fact  might  make  it  appear  to 
be  rarer  than  it  really  is.  The  external  variety  of  it,  however, 
which  occurs  as  a  complication  of  extensive  prolapsus,  is  not  par- 
ticularly uncommon,  and  will  often  be  found  referred  to  in  medical 
literature  under  the  head  of  "prolapsus  containing  loops  of  small 

intestine."     Such  reference  is  generally  limited  to  a  casual  men- 
11 


162 


SURGERY   OF  THE   RECTUM   AND   PELVIS. 


tion  of  the  possibility  of  the  condition,  and  the  condition  itself  has 
seldom  been  described  with  any  approach  to  completeness. 

There  are  several  varieties  of  this  affection,  that  in  which  the  sac 
is  composed  of  an  old  prolapsus  being  the  most  common.  This  may 
be  characterized  as  the  external  form.  In  this  the  sac  is  first  formed, 
and  remains  ready  at  any  time  for  the  reception  of  its  contents.  It 
may  never  be  occupied,  or  it  may  suddenly  be  filled  by  a  loop  of  in- 


FiG.  107. 
Internal  Rectal  Hernia. 


testine  as  a  result  of  a  sudden  strain  or  violent  action  of  the  abdomi- 
nal muscles.  There  is  another  variety,  which  may  be  known  as  the 
internal,  in  which  the  relation  is  somewhat  different.  In  it  the  rectal 
wall  at  some  especially  weak  point  yields  to  the  pressure  of  the 
pelvic  contents,  bulges  in  on  one  side  in  the  form  of  a  sac,  and  finally 
forms  a  considerable  tumor  occupying  the  rectal  pouch  (Fig.  107). 
The  favorite  site  for  such  a  sacculation  to  commence  is  at  the  recto- 
vesical cul-de-sac^  and  such  a  tumor  may  never  come  below  the 
sphincter. 


PROLAPSE.  163 

The  sac  of  an  internal  hernia  is  not  always  composed  of  all  the 
layers  of  the  gut,  for  the  reason  that  the  muscularis  is  apt  to  be 
weakened  before  such  a  condition  can  arise,  and  in  the  subsequent 
increase  in  growth  it  may  rupture  and  leave  only  peritoneum,  cellu- 
lar tissue,  and  mucous  membrane. 

Another  variety  is  that  in  which  no  proper  hernial  sac  can  be 
found,  the  coils  of  intestine  lying  loose  in  the  rectal  pouch  or  pro- 
jecting beyond  the  sphincter.  These  are  the  cases  described  as  spon- 
taneous rupture  of  the  rectum,  to  distinguish  them  from  the  results 
of  direct  traumatism,  such  as  might  be  caused  by  a  foreign  body 
puncturing  the  rectal  wall  or  the  pelvic  diaphragm.  Many  of  these 
cases  are  undoubtedly  the  result  of  the  rupture  of  a  previously  ex- 
isting hernial  sac,  and  are  therefore  merely  complications  of  the 
varieties  alread}^  described.  It  is  possible  that  rupture  of  the  rec- 
tum may  occur  as  a  result  of  severe  straining  where  there  has  been 
no  previous  hernia,  but  it  does  not  seem  probable  that  such  rupture 
ever  occurs  without  the  existence  of  previous  disease  which  has 
weakened  the  wall  of  the  rectum  at  the  point  where  the  rupture 
takes  place,  except  in  cases  of  direct  traumatism,  as  in  childbirth,  or 
the  introduction  of  foreign  bodies.  The  immediate  cause  of  the  rupt- 
ure is  probably  an  overdistention  of  the  sac  with  loops  of  intestine 
filled  with  gas  and  faeces,  and  then  a  straining  on  the  part  of  the 
patient  by  which  fresh  coils  of  intestine  or  more  air  and  faeces  are 
forced  into  the  sac. 

The  contents  of  the  hernial  sac  are  generally  loops  of  small  intes- 
tine ;  quite  frequently,  however,  portions  of  the  colon  and  sigmoid 
flexure  have  been  found,  and  occasionally  an  ovary  or  the  uterus. 
The  size  of  the  hernia  may  be  so  small  as  to  lead  the  unwary  into  the 
belief  that  it  is  a  simple  prolapse  composed  entirely  of  mucous  mem- 
brane, or  it  may  reach  the  dimensions  of  an  adult  head.  After  the 
rupture  of  the  sac  the  intestine  may  escape  to  the  length  of  several 
yards. 

Diagnosis. 

Nothing  need  be  said  upon  the  diagnosis  of  a  rectal  hernia  in 
which  the  coils  of  intestine  protrude  from  the  anus  uncovered  by 
any  hernial  sac.     In  an  internal  rectal  hernia  (one  which  has   not 


164  SURGERY    OF    THE   RECTUM    AND    PELVIS. 

passed  the  anus),  and  which  has  not  ruptured,  the  diagnosis  will 
lie  between  it  and  an  intussusception  ;  but  a  careful  examination 
with  the  finger  should  reveal  the  presence  of  a  sac  containing  loops 
of  intestine  which  can  be  pressed  out  of  it  into  the  general  peritoneal 
cavity  ;  of  a  pedicle  to  the  tumor  thus  formed  ;  and  of  an  opening  in 
the  wall  of  the  bowel  which  constitutes  the  mouth  of  the  sac. 

In  ordinary  cases  of  hernia  which  have  become  external,  the  diag- 
nosis will  lie  between  hernia  and  prolapsus  without  hernia.  Often 
the  different  coils  of  intestine  within  the  prolapsus  can  be  felt  be- 
tween the  fingers,  the  index  finger  being  passed  up  into  the  rectum 
and  the  thumb  remaining  outside.  The  coils  may  also  be  reduced 
from  the  sac  with  a  gurgling  noise,  and  the  sac  may  be  tympanitic 
on  percussion,  especially  in  front.  The  thickness  of  the  mass  and  its 
pear  shape  are  also  points  of  importance,  and  the  peculiar  enlarge- 
ment in  circumference  which  it  undergoes  when  the  patient  strains, 
instead  of  the  mere  lengthening  which  occurs  under  similar  circum- 
stances in  a  simple  prolapsus.  A  careful  examination  here  also  may 
enable  the  surgeon  to  trace  the  pedicle  up  into  the  pelvis,  and  the  po- 
sition of  the  opening  into  the  rectum,  as  it  is  turned  back  toward  the 
coccyx  by  the  bulging  of  the  anterior  portion  of  the  tumor,  is  worthy 
of  notice.  The  diagnosis  is  always  complicated  by  the  condition  of 
irreducibility,  but  even  here  tympanitic  resonance  on  percussion,  and 
gurgling  of  air  on  palpation,  remain  to  assist  the  examiner.  The 
flattened  appearance  of  the  lower  abdomen,  the  sinking  in  of  the 
umbilicus,  and  the  folds  of  the  abdominal  wall  radiating  from  it, 
may  also  indicate  that  the  abdomen  has  lost  a  part  of  its  natural 
•contents. 

Treatment. 

The  first  step  in  the  treatment  of  prolapse  to  which  the  surgeon 
will  be  called  to  attend  will  generally  be  to  effect  the  reduction 
of  the  mass  ;  after  this  has  been  accomplished  the  treatment  may 
be  either  palliative  or  curative.  In  children  a  prolapse  may  gen- 
erally be  reduced  by  laying  the  patient  across  the  lap  on  its  face 
and  making  gentle  pressure  on  the  protruded  bowel  with  the  fingers, 
which  have  been  well  oiled,  or  with  a  soft  greased  rag.  If  this  cannot 
be  accomplished  by  a  gentle  taxis  and  without  bruising  the  parts, 


PROLAPSE.  165 

the  child  should  at  once  be  etherized  and  a  curative  procedure 
adopted.  It  is  scarcely  worth  while  in  a  child  to  stop  to  try  the 
various  methods  of  reduction  which  have  been  recommended,  where 
the  taxis  has  failed,  before  resorting  to  this  step. 

In  an  adult,  however,  ether  and  operative  interference  may  both 
be  declined,  and  the  surgeon  may  have  to  tax  his  brain  to  accomplish 
the  reduction  without  the  aid  of  an  anaesthetic.  In  such  a  case,  after 
gentle  taxis  has  been  tried  with  the  patient  in  the  knee-elbow  posi- 
tion and  failed,  cold  should  be  applied  while  the  patient  remains  on 
the  face  in  bed  with  a  pillow  under  the  pelvis  ;  and  this  may  be 
alternated  with  warm  poultices  and  with  plentiful  applications  of  an 
ointment  composed  of  equal  parts  of  extract  of  belladonna  and  ex- 
tract of  opium.  By  these  means,  the  most  effectual  of  which  is  posi- 
tion, reduction  may  almost  always  be  accomplished.  When  by  the 
action  of  the  sphincter  the  prolapse  has  become  gorged  with  blood 
and  (Edematous,  the  surgeon  is  often  tempted  to  resort  to  leeches. 
They  will  generally  give  relief  and  may  greatly  facilitate  reduction, 
but  they  are  not  free  from  the  danger  of  a  concealed  hemorrhage 
within  the  rectum  after  the  prolapse  has  been  replaced.  Attempts 
at  manual  replacement  must  not  be  carried  far  enough  to  bruise  the 
parts  or  set  up  inflammatory  action. 

Two  questions  may  arise  in  this  connection.  Should  reduction  be 
tried  when  the  tumor  is  inflamed,  and  should  it  be  tried  in  case  of  a 
circular  slough  ?  In  answering  the  first  question,  the  distinction 
must  be  made  between  a  prolapse  which  is  merely  strangulated  and 
one  which  is  inflamed.  The  appearances  may  be  much  the  same, 
but  an  old  prolapse  in  an  old  person  when  found  in  this  condition  is 
much  more  apt  to  be  inflamed  than  strangulated,  for  the  sphincter 
muscle  in  such  cases  has  generally  lost  the  power  of  forcible  con- 
striction. The  danger  in  returning  an  inflamed  prolapse  into  the  body 
is  that  the  inflammation  may  extend  and  cause  general  and  fatal 
peritonitis  ;  and,  as  a  rule,  it  is  safer  not  to  employ  the  taxis  in  such 
a  case,  but  to  put  the  patient  in  bed  and  treat  it  by  local  applications 
and  rest  till  the  acute  symptoms  have  disappeared. 

The  occurrence  of  a  circular  slough  as  a  result  of  strangulation  is 
a  very  serious  complication.  The  tumor  is  generally  of  the  second 
variety,   has  become  first  irreducible,  then  inflamed,    and    finally 


166  SURGERY  OF  THE  RECTUM  AND  PELVIS. 

strangulated.  At  the  apex,  around  the  opening,  there  will  be  seen  a 
black  ring  of  dead  mucous  membrane  and  connective  tissue  of  greater 
or  less  extent,  perhaps  already  partially  separated  and  hanging  in 
shreds.  The  patient  will  exhibit  more  or  less  constitutional  disturb- 
ance and  fever,  with  fretfulness  and  evident  suffering. 

The  gravity  of  this  condition  consists  in  the  fact  that  a  cir- 
cular slough  is  very  apt  to  be  the  cause  of  a  severe  stricture 
after  cicatrization  has  occurred.  If  the  prolapse  be  a  long  one, 
and  the  slough  is  at  its  apex,  three  or  four  inches  from  the  anus, 
the  stricture  will  be  at  a  corresponding  distance  up  the  rectum  when 
it  is  reduced  ;  and  its  extent  and  severity  will  be  in  proportion  to 
the  amount  of  tissue  which  has  been  involved  both  longitudinally 
and  in  depth. 

The  treatment  of  this  complication  resolves  itself  into  the  ablation 
of  the  tumor.  In  this  way  the  future  stricture  is  removed,  and  what- 
ever contraction  there  may  be  resulting  from  the  operation  will  be  at 
the  anus,  where  it  is  easily  handled,  and  not  at  a  point  within  the 
rectum. 

The  palliative  treatment  is  directed  entirely  toward  diminishing 
the  frequency  and  the  amount  of  the  prolapse,  and  in  children  a  cure 
may  sometimes  be  obtained  by  these  means  without  resorting  to  surgi- 
cal interference.  The  act  of  defecation  is  first  to  be  regulated,  and 
should  be  performed  with  the  patient  in  the  recumbent  posture. 
One  buttock  may  also  be  drawn  aside  so  as  to  tighten  the  anal  ori- 
fice, with  advantage  ;  and  any  source  of  irritation  which  produces  fre- 
quent defecation  and  straining  in  the  act  must  be  removed.  After 
the  action  of  the  bowels,  if  the  prolapse  has  occurred,  the  bowel 
should  be  thoroughly  washed  with  cold  water  and  a  solution  of  alum 
(3i.  to  §  viij.)  before  it  is  returned.  Another  favorite  wash  is  com- 
posed of  the  tincture  of  iron,  twenty  to  thirty  drops  to  four  ounces 
of  water.  The  patient  should  then  be  confined  to  the  bed  for  some 
time,  and  pressure  should  be  applied  over  the  anus  by  a  pad  kept  in 
place  by  a  T-bandage  in  the  adult,  or  by  a  broad  strip  of  adhesive 
plaster  in  children,  applied  so  as  to  draw  the  buttocks  into  close  ap- 
position. 

If  any  palpable  cause  for  the  disease  can  be  found  it  must  be  re- 
moved.    I  have  cured  a  bad  case  in  a  child  by  doing  away  with  the 


PROLAPSE.  167 

irritation  caused  by  pin-worms.  Calculus,  phimosis,  constipation, 
and  polypus  must  all  be  remedied  if  tliey  are  present. 

After  the  bowel  has  ceased  to  come  down  with  the  act  of  defecation, 
an  astringent  injection  may  be  given  every  night  with  advantage  and 
allowed  to  remain  in  all  night.  The  general  health  should  be  care- 
fully attended  to  ;  tonics  should  be  administered  where  they  seem  to 
be  indicated  ;  and,  if  well  borne,  cod-liver  oil  may  be  used  to  fulfil 
the  double  indication  of  tonic  and  laxative.  In  children  these  meas- 
ures may,  as  has  been  said,  be  curative,  and,  in  fact,  the  disease  often 
ceases  spontaneously  at  about  the  time  of  puberty  ;  but  in  adults 
they  are  not  at  all  likely  to  be  so. 

After  inflammation  or  partial  strangulation  has  once  occurred, 
unless  it  has  worked  a  cure  by  sloughing,  it  is  almost  useless  to 
hope  for  a  cure  by  palliative  treatment.  The  conditions  have  be- 
come changed';  the  tumor  is  thickened  and  increased  in  size  ;  it  has 
become  too  large  for  its  former  natural  position  in  the  pelvis,  and 
acts  as  a  constant  source  of  irritation. 

Should  radical  operative  treatment  be  decided  upon,  there  are 
several  effectual  methods.  There  is,  in  fact,  one  principle  which  lies 
at  the  foundation  of  the  treatment  of  prolapse  by  operation.  If  the 
tumor  be  easily  reducible,  it  may  be  retained  in  the  body  by  dimin- 
ishing the  size  of  the  anus.  If  it  be  not  easil}^  reducible,  a  part  of 
it  may  have  to  be  removed,  the  remainder  reduced,  and  then  the 
anus  diminished  to  retain  it.  All  plans  of  treatment  are  directed 
toward  the  accomplishment  of  one  or  both  these  things,  and  it  re- 
mains only  to  choose  between  them. 

Incases  combined  with  internal  hemorrhoids,  the  operation  for  the 
removal  of  the  latter  by  either  the  clamp  or  ligature  may  easily  be 
extended  so  as  to  cure  at  the  same  time  the  former  condition.  In 
such  a  case  the  proper  course  to  pursue  is  to  divide  the  prolapse  into 
several  sections  with  the  scissors,  and  operate  upon  each  one  exactly 
as  though  it  were  an  internal  hemorrhoid.  Caution  must  be  exercised 
as  to  the  amount  of  tissue  riemoved,  lest  too  great  a  degree  of  cicatri- 
cial contraction  result. 


168  SUKGEKY   OF   THE   KECTUM   ANl)   PELVIS. 

Cauterization. 

In  cliildren  in  whom  milder  measures  have  failed,  a  very  ef- 
fectual means  of  cure  is  the  application  of  fuming  nitric  acid  to 
the  mucous  membrane  of  the  prolapsed  part.  The  bowel  should 
first  be  carefully  wiped  off  with  a  towel  or  sponge,  and  the  acid  then 
applied  by  means  of  a  small  stick  all  over  the  mucous  membrane, 
but  not  at  all  to  the  skin  adjacent.  Ether  is  not  necessary,  and  after 
such  an  application  the  bowel  should  be  replaced,  a  pad  of  lint  firmly 
applied  over  the  anus  by  means  of  broad  strips  of  adhesive  plaster, 
and  the  bowels  confined  by  means  of  opium.  Stuffing  the  rectum 
with  wool  causes  unnecessary  irritation.  After  three  or  four  days 
the  straps  may  be  removed  and  the  bowels  moved  with  castor 
oil  while  the  child  lies  in  bed  and  the  buttocks  are  pressed  to- 
gether by  the  nurse.  In  a  large  proportion  of  cases  the  cure  will 
be  found  complete,  though  in  a  few  cases  I  have  seen  a  return 
of  the  disease  after  a  few  months.  In  any  case,  however,  the  benefit 
will  be  found  to  be  very  great,  and  should  the  disease  return,  a  very 
careful  search  should  be  instituted  for  some  existing  source  of  irri- 
tation, such  as  polypus,  phimosis,  or  calculus.  In  case  of  a  recur- 
rence, a  second  application  will  be  effectual  in  causing  a  cure. 

This  treatment,  though  successful  in  children,  is  by  no  means 
always  so  in  adults.  Deep  sloughs  may  occur  in  old  persons  with 
debilitated  constitutions ;  and  as  a  result  of  such  a  slough  there 
may  be  severe  hemorrhage.  Stricture  of  the  rectum  may,  without 
doubt,  be  caused  by  too  free  use  of  this  remedy,  but  since  it  follows 
its  abuse  and  not  its  proper  use  in  appropriately  selected  cases,  it 
can  hardly  be  considered  an  objection. 

Linear  Cauterization. 

In  adults  this  is  undoubtedly  the  best  means  at  our  command 
for  dealing  with  all  but  the  gravest  cases  of  this  affection,  and 
the  best  means  of  applying  it  is  that  recommended  by  Van  Buren, 
with  Paquelin's  cautery. 

The  patient  is  first  etherized  and  placed  in  Sims' s  position.  Van 
Buren  reduced  the  prolapse,  and  applied  the  iron  with  the  aid  of 


PROLAPSE. 


169 


a  speculum,  though  I  prefer  that  the  iron  be  first  applied  and  the 
tumor  reduced  afterward.  In  either  case  from  three  to  six  vertical 
stripes  should  be  made  upon  the  mucous  membrane,  with  the  iron 
heated  to  a  dull-red  heat.  The  cauterizations,  according  to  Van 
Buren's  method,  should  begin  about  three  inches  up  the 
rectum,  and  end  at  the  junction  of  the  skin  and  mucous 
membrane.  They  should  also  be  deeper  at  the  end, 
where  there  is  no  danger,  than  at  the  beginning,  where 
the  bowel  may  be  perforated.  He  recommends  that 
the  iron  be  bent  at  a  right  angle  a  short  distance  from 
the  end,  so  that  it  may  be  the  more  thoroughly  ap- 
plied to  the  concavity  of  the  rectum,  and  that  in  mild 
cases  a  small  iron  should  be  used,  "  no  thicker  than  an 
ordinary  probe"  (Fig.  108).  I  use  the  ordinary  iron, 
and  burn  from  the  apex  of  the  tumor  to  the  sphincter, 
after  the  mass  has  been  well  pulled  down  with  forceps. 
In  bad  cases  the  sphincter  muscle  may  be  burned 
through  at  two  opposite  points,  after  reducing  the 
bowel.  By  this  burning  through  the  sphincter  the  pat- 
ulous condition  of  the  anus  is  overcome.  The  result  of 
the  operation  is  to  decrease  the  circumference  of  the 
anal  orifice,  and  also  to  bind  the  mucous  and  submu- 
cous to  the  muscular  coat  by  a  series  of  linear  cica- 
trices, and  in  this  way  to  effect  a  cure.  The  patient 
should  be  confined  absolutely  to  bed  till  the  wounds  are 
entirely  healed,  so  that  a  recurrence  of  the  descent  may 
be  effectually  avoided. 

For  some  time  after  the  healing,  and  after  the  patient 
is  allowed  to  be  up  and  about,  in  fact,  until  the  full 
effect  of  the  operation  has  been  obtained,  a  bed-pan 
should  be  used.  The  first  operation,  if  thoroughly  per- 
formed, will  probably  result  in  permanent  cure.  Should 
it  not,  it  may  be  repeated.  The  only  danger  in  con- 
nection with  it  is  the  occurrence  of  secondary  hemorrhage  when  the 
sloughs  separate,  and  of  primary  hemorrhage  from  large  veins  at 
the  time  of  the  application  of  the  iron. 


Fig.  108. 
Cautery   Iron. 


170  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

Amputation. 

The  moment  we  begin  to  tliink  of  catting  off  a  prolapse  we 
approach  the  danger  line.  Cauterization  is  almost  never  followed 
by  any  bad  results,  unless  it  is  carried  to  an  unnecessary  extent 
which  subsequently  produces  a  stricture ;  but  amputation  of  an 
apparently  innocent  tumor  may  be  fatal  from  a  wound  of  the 
peritoneum,  hence  the  necessity  for  the  care  in  diagnosis  already  in- 
sisted upon.  A  prolapse  consisting  of  the  mucous  membrane  alone 
may  be  amputated  in  toto  without  danger;  one  of  the  second  class 
must  be  approached  very  cautiously,  and  the  operator  need  not  be 
greatly  surprised  if  he  unexpectedly  opens  the  peritoneum. 

In  the  operation  much  judgment  and  experience  are  necessary  to 
decide  how  much  tissue  to  remove.  A  great  deal  of  subsequent  con- 
traction must  be  allowed  for,  and  a  troublesome  stricture  may  easily 
be  produced.  It  will  generally  be  sufficient  to  remove  two  or  three 
longitudinal  strips,  and  perhaps  to  then  burn  through  the  sphincter 
in  a  couple  of  places.  The  part  to  be  removed  is  seized  in  the  clamp, 
which  is  thoroughly  screwed  up,  and  cut  off  with  scissors.  A  con- 
siderable stump  must  be  left,  and  this  must  be  thoroughly  burned 
with  the  cautery  heated  to  a  dull  red.  If  the  iron  be  white  the  dan- 
ger of  bleeding  is  increased.  After  the  iron  has  been  thoroughly 
applied  to  every  part  of  the  cut  surface,  the  clamp  may  be  relaxed, 
bat  should  not  be  removed  till  it  is  evident  that  there  is  to  be  no 
bleeding. 

After  such  an  operation,  what  is  left  of  the  tumor  should  be  re- 
duced, if  possible,  and  the  pad  and  bandage  applied  as  after  linear 
cauterization.  In  case  the  tumor  is  still  too  hard  and  swollen  to  be 
reduced,  even  after  the  operation,  it  must  be  dressed  with  a  cold 
compress,  and  the  case  left  until  the  shrinkage  which  is  sure  to  fol- 
low has  taken  place.  After  this  operation  the  treatment  is  somewhat 
different  from  that  after  the  simple  linear  cauterization.  In  the  latter 
the  tumor  still  exists,  and  care  must  be  taken  to  prevent  its  coming 
out  of  the  body  by  confining  the  bowels.  After  the  clamp  has  been 
used,  it  is  generally  better  to  encourage  the  bowels  to  move  after  the 
second  day  by  the  administration  of  a  saline  or  the  compound  licorice 
powder. 


PROLAPSE.  171 

The  suffering  after  this  operation  is  not  generally  severe.  No 
dressing  of  the  wound  is  required  except  frequent  washing  with  warm 
water  and  the  application  of  a  soft  cloth  to  the  parts  to  catch  the 
discharge  which  escapes  from  the  anus.  The  patient  should  be  kept 
in  bed  till  the  wounds  are  entirely  healed,  and  for  the  first  few  days 
the  surgeon  must  inquire  carefully  after  the  action  of  the  bladder. 
All  things  considered,  the  operation  is  a  very  satisfactory  one,  much 
more  so  than  the  analogous  operation  of  removing  sections  of  the 
tumor  with  the  ligature. 

There  remains  to  be  considered  the  small  class  of  cases  of  extensive 
disease  which  cannot  be  cured  by  any  method  so  far  enumerated, 
and  which  lead  us  at  once  into  the  domain  of  major  surgery.  At- 
tempts have  been  made  to  suture  the  sigmoid  flexure  or  upper  rectum 
to  some  point  within  the  pelvis,  such,  for  example,  as  the  promontory 
of  the  sacrum,  and  thus  prevent  the  descent  of  the  bowel,  but  not 
with  any  great  success. 

Ventral  Fixation  of  Prolapse. 

In  a  few  cases  I  have  opened  the  abdomen  and  stitched  the  sig- 
moid flexure  to  the  abdominal  wall,  in  much  the  same  way  as  in  ven- 
tral fixation  of  the  uterus,  and  my  success  has  been  greater  than  I 
anticipated,  giving  me  a  couple  of  rather  remarkable  cures.  The 
method  is,  however,  only  adapted  to  cases  of  intussusception  of  the 
upper  rectum  or  sigmoid  flexure  into  the  lower,  and  would,  I  think, 
hardly  succeed  in  an  old  incurable  case  of  simple  prolapsus,  even 
though  it  might  be  of  the  complete  variety. 

My  reason  for  supposing  this  is  that  it  is  impossible  to  stitch  any 
part  of  the  sigmoid  or  upper  rectum  to  the  abdominal  wall  which 
would  be  near  enough  to  the  portion  prolapsed  to  act  as  a  permanent 
support  for  it. 

Resection  of  Prolapse. 

In  these  cases  we  are  reduced  to  a  simple  resection  of  the  pro- 
lapsed gut,  an  operation  which  necessarily  includes  opening  the  per- 
itoneum and  which  requires  all  the  attention  to  antisepsis  and  de- 
tails which  would  be  required  in  a  resection  of  any  other  piece  of 
intestine. 


172 


SUEGERT  OF  THE  KECTUM  AND  PELVIS. 


The  instruments  necessary  are  : 
Scalpel. 

Straight,  blunt-pointed  scissors. 
Six  haemostatic  forceps. 
Fine  catgut. 

Full-curved  medium-sized  needles. 
Needle-holder. 

After  thoroughly  scrubbing  the  perineum  and  shaving  it,  the  rec- 
tum should  be  well  irrigated  with  1  to  500  bichloride. 

The  prolapsus  should  then  be  brought  down  to  its  fullest  extent 
by  traction  with  the  haemostatic  forceps  upon  the  mucous  membrane. 
This  can  easily  be  done  by  catching  it  first  on  one  side  and  then  oa 


Fig.  109. 
Prolapse  with  Peritoneum  Opened. 


the  other,  and  gently  everting  it.  AVhen  all  has  been  brought  down 
the  last  pairs  of  forceps  may  be  left  attached,  and  they,  by  their  mere 
weight,  will  prevent  its  return. 

The  prolapse  should  next  be  thoroughly  scrubbed  with  soap  and 
brush,  irrigated  with  1  to  500  bichloride,  and  wiped  with  pledgets  of 


PROLAPSE. 


173 


iodoform  gauze  ;  and  all  of  the  subsequent  steps  of  the  operation 
should  be  done  under  a  stream  of  sterilized  water. 

With  a  knife  an  incision  is  made  through  the  mucous  membrane 
■only,  across  the  anterior  half  of  the  mass  just  below  the  external 
sphincter,  and  with  the  handle  of  the  scalpel  the  mucous  membrane 
of  this  portion  is  turned  down  as  far  as  the  apex  of  the  tumor.  But 
little  bleeding  will  follow  such  a  blunt  dissection,  although  consider- 
able may  be  caused  by  the  preliminary  incision. 

The  posterior  segment  of  the  tumor  is  next  treated  in  the  same 
way,  the  result  being  that  the  mass  is  entirely  deprived  of  its  mu- 
•cous  membrane  as  far  up  into  the  gut  as  the  operator  may  think 
necessary.  In  many  cases  of  very  large  tumors  this  removal  of  the 
mucous  membrane  will  so  diminish  the  size  of  the  tumor  that  it  will 
be  unnecessary  to  proceed  any  farther.  The  detached  mucous  mem- 
brane may,  under  these  circumstances,  be  amputated,  and  the  cut 
€dges  stitched  to  the  sphincter,  thus  completing  the  operation. 

In  other  cases  after  the  removal  of  the  mucous  membrane  it  will 
be  evident  that  only  the  covering  of  the  tumor  has  been  removed 
and  that  the  mass  of  the  prolapse  consisting  of  fat,  peritoneal  sac, 
and  possibly  intestinal  contents  still  remains.  The  fat  must  be  re- 
moved in  pieces  and  the  peritoneal  sac  opened  and  excised.  Fig. 
109.  The  same  care  and  deliberation  are  necessary  as  in  any  oper- 
ation for  hernia.  The  peritoneal  pouch  will  generally  be  found  on 
the  anterior  segment  of  the  tumor  and  seldom  in  both  anterior  and 
posterior.  After  the  sac  has  been  excised  the  peritoneal  edges  are 
united  with  fine  cat-gut,  and  the  suture  of  the  mucous  membrane 
completed  as  in  the  previous  case. 

The  dressing  should  consist  of  a  large  pad  and  firm  straps  of  ad- 
hesive plaster  to  draw  the  buttocks  together.  This  should  be  allowed 
to  remain  for  at  least  a  week.  The  bowels  may  then  be  gently  en- 
€ouraged  to  move  by  salines,  the  patient  lying  upon  a  bed-pan  and 
the  nurse  pressing  the  buttocks  together  to  prevent  any  extrusion  of 
the  bowel  during  the  act.  This  precaution  should  be  observed  for 
at  least  a  fortnight.  ' 

Verneuil  has  invented  a  new  method,  which  consists  in  dissecting 
down  upon  the  rectum  from  behind  in  the  median  line,  gathering  it 
up  into  transverse  folds  by  sutures  in  its  walls   which  do  not  pene- 


174  SURGERY   OF   THE   KECTUM   AXD   PELVIS. 

trate  its  calibre,  and,  after  thus  shortening  the  tube,  attaching  it  by- 
sutures  to  the  sides  of  the  coccyx  and  sacrum  to  prevent  its  further 
descent. 

In  cases  in  which  curative  measures  are  out  of  the  question,  the 
hemorrhages  and  the  erosions  may  be  relieved  by  suitable  applica- 
tions, rest  in  bed,  defecation  in  the  recumbent  posture,  etc.  Sub- 
sulphate  of  iron  is  perhaps  as  good  an  application  to  the  bleeding 
surface  as  any  other ;  and  weak  solutions  of  nitrate  of  silver  often 
have  a  good  effect  upon  the  erosions. 


CHAPTER  XI. 

INTUSSUSCEPTION. 

The  essential  difference  between  the  disease  now  to  be  considered 
and  the  forms  of  prolapse  already  described,  consists  in  the  fact 
that  while  in  the  latter  the  bowel  begins  to  slip  down  from  its  lowest 
portion  at  the  anus,  in  the  former  the  lowest  portion  remains  in  its 
proper  position  and  the  bowel  from  above  is  telescoped  within  it. 
Under  these  circumstances  it  is  evident,  as  is  shown  in  Fig.  110,  that 
the  affected  portion  of  the  bowel  must  consist  of  three  different  and 


flBTUfilHli 


Fig.  no. 
Int  issuscepfcion. 

distinct  cylinders — an  outer  one,  which  contains  the  other  two,  and 
two  included  portions,  one  of  which  is  the  entering  and  the  other 
the  returning  bowel. 

When  the  upper  part  of  the  rectum  becomes  invaginated  in  this 
way  within  the  lower,  the  included  portion  will  not  always  appear 
at  the  anus,  as  in  the  cases  of  prolapse  already  described,  and  yet 
there  is  little  doubt  in  my  mind  that  the  upper  part  of  the  rec- 
tum may  occasionally  become  invaginated  into  the  lower  without 
causing  any  symptoms  except  great  difficulty  in  defecation. 

This  is  a  rare  form  of  disease,  though  it  is  frequently  supposed  to 


176 


SURGERY   OF  THE   RECTUM   AND   PELVIS. 


exist  to  account  for  old  and  severe  cases  of  constipation.  The  symp- 
toms are  peculiar,  and  are  yet  almost  diagnostic  if  tlie  patient  be 
sufficiently  intelligent  to  make  himself  understood.  The  thing  most 
decidedly  complained  of  is  a  peculiar  straining  and  difficulty  in  defe- 
cation. The  patient  will  say  that  when  he  strains  the  bowel  seems 
to  become  closed,  and  that  no  amount  of  effort  will  overcome  the 
obstruction.  This  story  is  common  enough  and  means  nothing  but 
constipation.  But  when  he  or  she  complains  that  to  have  a  passage 
an  unnatural  position  has  to  be  assumed,  I  always  begin  to  be  sus- 
picious of  intussusception.  One  of  my  patients  could  only  relieve 
himself  in   the  knee-elbow  position,    and  another  only  when  lying 


Fig.  111. 
Prolapse  of  Invaginated  Intestine. 


down.  When  this  history  is  given,  and  a  digital  examination  shows 
an  absence  of  any  change  in  the  gut,  such  as  stricture,  a  temporary 
invagination  at  the  time  of  defecation  may  be  strongly  suspected. 
It  is  possible  in  some  cases  to  feel  the  tumor  caused  by  the  condition 
in  the  rectum  when  the  patient  assumes  the  natural  position  of  defe- 


INTUSSUSCEPTION".  177 

cation  and  strains  down.  The  treatment  consists  in  linear  cauteriza- 
tion of  the  upper  part  of  the  rectum.  The  iron  should  be  an  old- 
fashioned,  olive-pointed,  actual  cautery  iron  with  small  tip,  heated 
scarcely  more  than  black,  and  applied  lightl}^  at  four  or  five  points. 
The  thermo-cautery  is  too  powerful  an  instrument,  for  it  must  be  re- 
membered that  the  peritoneum  is  just  under  the  iron.  My  preference, 
however,  in  the  future  will  be  for  the  operation  of  ventral  fixation 
already  referred  to  under  prolapse. 

When  the  invagination  is  of  sufficient  extent,  a  distinct  sulcus 
may  be  felt  by  the  finger  between  the  extruded  portion  and  the  mu- 
cous membrane,  which  is  continuous  with  that  of  the  anus.  The 
bottom  of  this  sulcus,  or  the  point  at  which  the  entering  portion  be- 
comes directly  continuous  with  that  into  which  it  enters,  may  also 
be  felt  by  the  finger  if  it  is  low  enough  down  ;  if  not,  it  may  some- 
times be  detected  by  the  aid  of  a  soft  catheter.  When  a  portion  of 
the  bowel  still  farther  removed  from  the  anus  has  become  invagi- 
nated  into  that  immediately  below,  the  included  portion  may  or  may 
not  descend  sufficiently  near  to  the  anus  to  be  felt  by  rectal  touch, 
and  the  sulcus  may  not  be  apparent.  It  is  evident  that  between  a 
case  of  prolapse  in  which  all  the  coats  of  the  rectum  appear  through 
the  anus,  and  in  which  a  sulcus  can  be  felt  by  the  finger  passed 
around  the  protruded  portion,  and  a  case  in  which  the  ileum  is  tele- 
scoped through  the  ileo-csecal  valve  and  appears  at  the  anus,  the  dif- 
ference is  one  of  degree,  and  of  location,  and  not  of  kind. 

Such  a  protrusion  as  this  is  evidently  composed  of  an  entering 
and  returning  portion  of  the  bowel,  each  in  its  whole  thickness,  and 
between  them  there  are  two  surfaces  of  peritoneum  in  apposition,  one 
covering  the  descending  and  the  other  the  ascending  portion.  The 
peritoneal  cul-de-sac  thus  formed  is  generally  empty  ;  if  there  has 
been  sufficient  inflammation  the  serous  surfaces  may  have  become 
united  to  each  other. 

The  diagnosis  of  this  form  of  prolapse  rests  chiefly  upon  the  pres- 
ence of  the  sulcus ;  and  this  is  the  first  point  to  be  determined  in 
the  examination  of  every  case.  The  size  is  of  little  value  in  the  diag- 
nosis. An  inch  of  rectal  mucous  membrane  may  protrude  in  the 
first  form,  or  an  inch  of  the  ileum  may  protrude  in  the  third,  and  at 
first  sight  they  may  appear  very  much  alike.     A  large,  cocoanut- 

12 


178  SURGEKY   OF   THE   RECTUM   AND   PELVIS. 

shaped  tumor  is  generally  of  the  second  variety,  while  a  very  long 
one  is  more  apt  to  be  of  the  third.  An  intussusception  in  the  course 
of  the  intestine  at  a  distance  from  the  anus  is  not  likely  to  project 
more  than  a  few  inches  outside  the  body. 

The  sulcus  merely  proves  the  fact  of  invagination;  but  when  we 
consider  that  the  ileum  projecting  through  the  anus  has  been  mis- 
taken for  cancer,  polypus,  and  hemorrhoids,  that  it  has  been  cauter- 
ized, incised,  and  cut  off,  and  that  these  errors  in  diagnosis  have  led 
to  fatal  results,  its  importance  as  a  diagnostic  point  can  hardly  be 
overestimated. 

In  Fig.  112  is  shown  a  diagram  of  an  intussusception  any- 
where along  the  length  of  the  gut.  The  conditions  are  essentially 
the  same. 

There  is  the  ensheathing  part,  1 ;  the  entering  portion,  3  ;  and  the 
returning  portion,  2,  which  must  be  carefully  distinguished  from 
each  other.    The  former  (1)  is  sometimes  spoken  of  as  the  intussus- 


c 

^  ,.-'' 

4   V 

------' 

6   -. 

^^ 

; 

-- 

N           )          '. 

-     -J 

• 

12                   3 
Fig.  112. 
Intussusception. 

cipiens,  and  the  other  two  combined  as  intussusceptum.  Within  the 
sulcus  (6)  two  mucous  surfaces  are  in  contact  with  each  other,  and 
within  the  space  (5)  two  serous  surfaces.  The  point  (4)  where  the 
entering  portion  (3)  becomes  the  returning  portion  (2)  is  known  as  the 
apex  of  the  intussusception,  and  the  point  (7)  where  the  returning 
portion  joins  the  sheath  is  the  neck. 

Of  this  condition  there  are  many  varieties  and  degrees.     The  most 


INTUSSUSCEPTION.  179 

common,  forming  nearly  one-lialf  of  all  the  cases,  is  the  ileo-cfecal, 
or  that  in  which  the  ileum  and  the  caecum  pass  into  the  colon,  carry- 
ing the  ileo-csecal  valve  at  the  apex.     This  variety  also  is  the  most 
extensive,   the  caecum  sometimes  passing  the  whole  length  of  the 
colon  and  protruding  from  the  anus.     The  next  most  frequent  form 
is  that  which  is  confined  to  the  small  intestine  ;  more  frequently  to 
the  lower  part  of  the  jejunum,  but  quite  often  to  the  ileum,  and  oc- 
casionally to  the  duodenum.     In  these  the  amount   invaginated  is 
generally  short  and  the  tumor  correspondingl}''  small.     After  these  in 
frequency  come   the  cases  affecting  the  colon,  sigmoid  flexure,  and 
rectum.     When  the  large  bowel  is  affected  it  is  most  often  near  its 
termination,  the  descending  portion  passing  into  the  sigmoid  flexure, 
the  flexure  into  the  rectum,  or  the  upper  part  of   the  rectum  into  the 
lower.     These  latter  forms  are  necessarily  limited  in  extent,  for  when 
once  the  invagination  has  been  fairly  formed,  and  after  the  entering 
portion  has  been  grasped,  the  increase  in  length  is  always  at  the  ex- 
pense of  the  sheath.    The  apex  (Fig.   112)  remains  constantly  the 
same,  and  the  turning-in  is  not  done  at  this  point,  but  at  the  neck. 
If,   therefore,  the   neck   be  within   the   rectum,  the   intussusception 
must  be  limited  by  the  length  of  the  rectum  remaining  between  the 
neck  and  the  anus,  and  must  be  comparatively  short. 

An  intussusception  of  the  rectum  or  sigmoid  flexure  will  also,  as 
a  rule,  be  straighter  and  less  curved  than  one  of  the  bowel  higher  up 
because  of  the  absence  of  the  mesentery  in  the  tumor.  As  the  invo- 
lution goes  on  at  the  neck  of  the  tumor,  the  mesentery  is  drawn  in 
between  the  two  inner  layers,  in  the  form  of  a  cone,  with  the  base  up- 
ward. The  traction  upon  this  causes  a  curve  of  the  contained  cylin- 
der, the  concavity  of  which  is  toward  the  attachment  of  the  mesen- 
ter}^  In  the  small  intestine  this  curve  is  very  marked  at  times,  and 
the  meso-colon  may  cause  the  same  appearance  in  cases  involving  the 
large  bowel.  The  traction  of  the  mesentery  causes,  also,  other 
changes.  The  axis  of  the  contained  portion  is  not  the  same  as  that 
of  the  sheath,  and  the  oriflce  is  drawn  into  a  slit-like  shape  and 
turned  against  the  side  of  the  sheath,  so  that  it  may  be  difficult  to 
detect  it  with  the  finger.  The  curve  of  the  inner  portions  may  be  so 
sharp  as  to  cause  complete  obstruction,  and  the  pressure  upon  the 
sheath  may  be  so  great  as  to  cause  sloughing  and  perforation.     This 


180  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

is,  indeed,  the  chief  cause  of  the  obstruction  which  results  from  in- 
tussusception, though  the  obstruction  may  not  become  complete 
until  some  indigestible  substance  has  been  propelled  into  the  already 
narrowed  passage,  or  until  the  lumen  becomes  almost  completely 
closed  by  a  gradual  thickening  of  the  different  layers  of  the  gut,  due 
to  congestion  and  inflammatory  exudation  in  their  walls. 


Fio.  113. 
Intussusception. 

The  obstruction,  and  the  strangulation  which  are  generally  pres- 
ent to  a  greater  or  less  degree,  cause  certain  other  changes.  The 
bowel  above  the  implicated  portion  may  be  simply  distended  and 
congested,  it  may  be  filled  with  a  large  mass  of  faeces,  or  it  may  be 
ulcerated  and  perforated.  If  the  case  has  been  acute,  death  may  su- 
pervene before  any  of  these  effects  are  noticeable ;  if  chronic,  there 
may  be  more  or  less  thickening  from  infiltration. 

The  serous  surfaces  in  apposition  in  the  two  contained  portions 
are  apt  to  become  united  by  adhesions  due  to  peritonitis.     These 


INTUSSUSCEPTION. 


181 


may  be  found  at  any  part  of  the  intussusception,  and  may  vary  much 
in  extent.  There  may  be  only  a  few  bands  near  the  apex  or  neck, 
or  the  two  surfaces  may  be  completely  agglutinated. 

The  adhesions  may  appear  at  any  time  after  the  third  day,  may 
be  extensive  in  an  acute  case  or  absent  in  a  chronic  one,  and  there  is 
no  regularity  in  the  time  of  their  appearance  or  their  extent.  When 
present  they  are  the  chief  obstacle  to  reduction,  whether  spontaneous 
or  the  result  of  any  kind  of  treatment. 

The  strangulation  of  the  contained  portion  may  cause  in  it  cer- 
tain other  changes.     The  walls  may  become  much  swollen  by  the 


Fig.  114. 
IntusBusception. 


transudation  of  serum,  the  peritoneum  congested,  the  mucous  mem- 
brane infiltrated  ;  blood  is  effused  between  the  mucous  surfaces  of  the 
outer  and  middle  layers,  and  the  whole  contained  portion  becomes  in 
this  way  irreducible.     Should  the  strangulation  be  sufficiently  severe. 


182  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

gangrene  may  supervene  upon  this  condition.  This  is  nature's 
method  of  cure.  It  is  more  apt  to  take  place  in  acute  than  chronic 
cases,  and  may  involve  the  whole  or  only  a  part  of  the  contained 
portion.  As  a  result  many  feet  of  bowel  may  slough  off  and  be 
passed  in  cylindrical  form,  or  only  small  portions  of  mucous  mem- 
brane may  be  discharged.  In  one  case  there  is  reason  to  believe  that 
about  four  yards  came  away,  piece  by  piece,  jper  anum. 

The  disease  is  twice  as  common  in  males  as  in  females,  and  is 
greatly. more  common  in  children  than  in  adults.  More  than  one-half 
the  whole  number  of  cases  occur  in  children  under  ten  years,  and  of 
these  nearly  one-half  occur  before  the  age  of  one  year.  In  adults 
the  trouble  will  generally  be  found  to  involve  the  small  intestine  ;  in 
children,  the  large. 

Strangulation  is  much  more  frequent  where  the  outer  layer  is 
composed  of  the  small  than  where  it  is  composed  of  the  large  intes- 
tine, because  of  the  greater  tightness  of  the  constriction.  In  the 
latter  case  the  congestion  may  be  only  moderate  in  degree,  and  the 
condition  may  last  many  weeks  without  gangrene  or  ulceration. 
This  condition  is  known  as  chronic  intussusception. 

If  sloughing  occur  at  all,  it  may  happen  at  any  time  after  the  first 
week  ;  generally,  however,  it  occurs  within  three  weeks,  though  it 
may  be  delayed  for  a  much  longer  time.  In  one  case  the  separation 
of  fragments  of  intestine  extended  over  an  interval  of  three  years. 

In  about  one-half  of  the  reported  cases  a  favorable  termination 
lias  followed  spontaneous  separation  ;  in  the  remainder  death  has 
occurred  after  a  longer  or  shorter  interval.  Several  pathological 
changes  may  occur.  The  peritonitis  which  serves  to  unite  the  serous 
surfaces  of  the  contained  portions  may  become  general  and  cause 
death.  The  ensheathing  portion  may  become  ulcerated  and  perfo- 
rated, allowing  of  the  extravasation  of  fseces.  The  ulceration  may 
perhaps  be  due  to  the  lateral  pressure  of  the  end  of  the  contained 
portion  against  the  side  of  the  cylinder  which  contains  it.  Separa- 
tion by  sloughing  leaves  the  upper  end  of  the  ensheathing  portion 
united  with  the  lower  end  of  the  healthy  bowel,  and  results  in  com- 
plete amputation  of  the  contained  portion.  Extravasation  may  also 
occur  from  a  deficiency  in  this  union  at  the  time  when  separation 
occurs. 


INTUSSUSCEPTION.  183 

While  these  pathological  changes  are  going  on  in  the  contained 
portion,  the  sheath  may  show  comparatively  little  change  beyond 
some  congestion  and  thickening. 

In  studying  the  symptoms  and  diagnosis  of  this  affection,  it  is 
best  to  accept  the  arbitrary  division  of  cases  which  has  been  made 
into  the  ultra-acute,  acute,  subacute,  and  chronic.  In  the  first  the 
patient  dies  within  twenty-four  hours.  The  second  covers  the  cases 
which  last  from  two  days  to  one  week  ;  the  third,  those  lasting  from 
a  week  to  a  month  ;  and  the  fourth,  those  lasting  more  than  a 
month. 

In  acute  cases  the  symptoms  will  be  found  to  vary  somewhat, 
according  to  the  part  implicated,  but  the  attack  generally  be- 
gins with  a  sudden  and  violent  pain.  The  pain  resembles  colic,  is 
intermittent,  and  may  or  may  not  be  accompanied  by  vomiting.  If 
the  rectum  be  implicated,  the  first  symptoms  may  be  tenesmus, 
bloody  passages,  and  the  appearance  of  the  intussusceptum  at  the 
anus.  The  strangulation  and  engorgement  cause  diarrhoea,  tenesmus, 
and  bloody  passages  after  a  time,  whatever  part  of  the  bowel  is  af- 
fected. It  is  rare  that  the  lumen  of  the  gut  is  so  completely  closed 
that  no  faeces  pass. 

In  about  one-half  of  all  the  cases  a  tumor  can  be  felt,  and  this 
symptom  is  more  frequent  in  children  than  adults.  It  varies  in  loca- 
tion according  to  the  part  involved  ;  is  usually  hard  and  resisting  ; 
is  more  prominent  when  active  peristalsis  occurs  ;  and  may  change 
its  position  when  the  bowel  is  contracting  strongly,  or  may  be  moved 
by  enemata.  It  is  not  generally  very  large,  and  its  size  is  no  indica- 
tion of  the  amount  of  intestine  involved.  In  quite  a  large  proportion 
of  cases,  especially  in  children,  it  may  either  be  felt  in  the  rectum  or 
be  seen  projecting  from  the  anus.  When  within  the  rectum,  the  soft, 
velvety  feel,  the  sulcus,  and  the  slit-like  orifice  into  which  the  finger 
can  be  passed  present  characteristic  signs  of  its  nature.  When  it 
projects  from  the  anus,  the  presenting  part  is  not  generally  more 
than  three  or  four  inches  in  length,  is  conical  in.  form,  and  its  nature 
may  sometimes  be  diagnosticated  by  the  appearance  of  the  ileo-csecal 
valve  and  the  orifice  of  the  appendix  vermiformis.  This  variety  of 
intussusception  is  more  often  chronic  than  acute,  and  the  tumor 
does  not,  as  a  rule,  appear  at  the  anus  until  after  the  symptoms  have 


184  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

lasted  from  one  to  three  weeks,  while  in  an  acute  case  it  may  be  dis- 
covered on  the  second  day. 

Vomiting  of  some  kind  is  a  nearly  constant  symptom  of  intussus- 
ception, but  it  varies  much  in  character  and  in  the  time  of  appear- 
ance. The  more  acute  the  case,  and  the  higher  up  the  disease,  the 
sooner  will  it  appear  and  the  sooner  will  it  become  stercoraceous.  In 
cases  involving  the  rectum  it  may  never  be  present,  while  in  those 
involving  the  ileum  it  may  be  the  earliest  symptom.  Stercoraceous 
vomiting  is  rather  a  sign  of  complete  obstruction  than  an  indication 
of  its  location.  It  is  only  present  in  about  twenty-five  per  cent,  of 
the  acute  cases  and  seven  per  cent,  of  the  chronic,  and  Treves  points 
out  that  it  has  a  direct  dependence  upon  the  diarrhoea.  Where  the 
latter  is  marked  and  constant  the  vomiting  is  comparatively  slight, 
and  vice  versa.  In  other  words,  where  the  obstruction  is  not  com- 
plete the  bowels  relieve  themselves  in  the  natural  direction. 

In  the  acute  form  the  constitutional  state  can  hardly  fail  to  attract 
attention.  In  young  children  it  is  simply  one  of  collapse,  and  the 
more  acute  the  case  the  greater  the  shock.  The  ultra-acute  cases 
(those  fatal  within  the  first  twenty-four  hours)  are  fatal  from  shock, 
and  are  almost  always  seen  in  very  young  children. 

In  chronic  cases  the  symptoms  are  all  more  obscure,  as  will  be 
apparent  from  the  fact  that  the  condition  has  been  mistaken  for  al- 
most every  form  of  disease  of  the  abdomen.  The  course  of  the  dis- 
ease is  irregular,  the  pain  uncertain  and  often  absent  for  long  periods ; 
the  passages  may  be  normal  at  times,  alternating  with  both  diarrhoea 
and  constipation,  and  occasionally  streaked  with  blood  ;  the  vomit- 
ing is  not  constant,  and  feculent  vomiting  is  rare ;  the  general  con- 
dition of  the  patient  is  that  of  one  suffering  from  chronic  disease. 
The  end  may  come  from  the  onset  of  complete  obstruction  with  the 
usual  symptoms,  or  simply  from  exhaustion  and  the  effects  of  long- 
continued  partial  obstruction. 

Prognosis. 

The  prognosis  in  all  varieties  of  intussusception  is  bad,  the  gen- 
eral mortality  in  all  forms  being  seventy  per  cent.  The  younger  the 
patient  the  more  acute  will  be  the  disease  and  the  greater  the  mor- 


INTUSSUSCEPTION.  185 

tality.  The  ultra-acute  cases  are  rare,  but  are  all  fatal.  The  acute 
cases  are  very  fatal,  and  especially  so  in  children.  The  chronic 
cases  are  nearly  all  fatal,  and  the  best  results  are  found  in  the  sub- 
acute, or  those  lasting  from  a  week  to  a  month. 

Spontaneous  cure  may  occur  in  three  ways:  1st,  by  reduction  ; 
2d,  by  elimination  ;  3d,  by  the  production  of  a  fecal  fistula.  Spon- 
taneous reduction  is  rare,  and  the  diagnosis  is  always  open  to  doubt. 
It  can  only  be  suspected  from  the  relief  which  sometimes  quite  sud- 
denly follows  all  the  symptoms  of  intussusception  ;  and  it  can  only 
happen  in  cases  where  the  physical  changes  have  been  comparatively 
slight  and  no  extensive  adhesions  have  formed. 

According  to  Treves  spontaneous  elimination  occurs  in  about 
forty-two  per  cent,  of  all  cases,  and  is  extremely  rare  in  children 
under  two  years  of  age.  It  is  much  more  common  in  the  variety 
affecting  the  small  intestine  than  in  any  other.  Cure  by  the  estab- 
lishment of  a  fecal  fistula  is  so  rare  as  to  be  almost  unknown. 

The  fact  that  the  intussuscepted  portion  is  sloughing  off  can  gen- 
erally be  made  out  pretty  clearly  by  the  symptoms.  If  the  obstruc- 
tion has  been  complete,  the  passages  again  appear  and  are  bloody, 
foul,  and  marked  by  small  shreds  of  gangrenous  mucous  membrane 
or  by  large  pieces  of  gut.  If  the  case  is  to  terminate  favorably,  there 
will  also  be  an  abatement  of  the  worst  symptoms,  but  quite  a  large 
proportion  of  cases  die  even  after  elimination  has  begun,  from  ex- 
haustion, perforation,  or  subsequent  ulceration. 


Diagnosis. 

The  diagnosis  of  the  fact  of  intestinal  obstruction  is  by  no 
means  always  eas}^  for  there  are  many  other  conditions  marked 
by  pain,  vomiting,  and  constipation,  which  are  its  three  chief 
symptoms  ;  but  having  accomplished  so  much,  the  diagnosis  be- 
tween intussusception  and  the  many  other  causes  of  obstruction  is 
sometimes  an  impossibility.  Under  these  circumstances  the  discovery 
of  the  end  of  the  invaginated  portion  in  the  rectum  with  its  sulcus 
around  it  makes  everything  plain  at  once. 

Moreover,  after  the  existence  of  intestinal  obstruction  has  been 


186  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

made  out  in  a  child  it  is  safe  to  consider  an  intussusception  as  the 
cause,  and  act  accordingly,  examples  of  other  forms  of  obstruction 
in  them  being  very  rare. 

If  the  patient  be  an  adult  and  rectal  touch  throws  no  light  upon 
the  case,  the  next  point  is  whether  the  condition  be  acute  or  chronic. 
If  acute,  the  diagnosis  will  rest  between  intussusception  on  the  one 
hand,  and  volvulus,  hernia  (either  external  or  concealed),  strangula- 
tion by  bands,  obstruction  by  foreign  bodies  (generally  a  gall-stone), 
and  peritonitis  with  perforation,  on  the  other.  A  few  hints  are  all 
that  can  be  given  to  aid  at  the  bedside,  and  mistakes  must  be  ex- 
pected. Volvulus  generally  affects  the  sigmoid  flexure,  and  the  pain 
is  apt  to  be  referred  to  that  spot.  It  is  a  disease  of  adult  life  and 
old  age.  The  constipation  is  absolute,  not  even  allowing  of  the  pas- 
sage of  blood.  There  is  no  distinct  tumor,  and  there  is  apt  to  be 
constant  tenesmus. 

With  hernia  of  any  kind,  or  strangulation  by  bands,  there  is 
likely  to  be  a  history  of  former  attacks  of  peritonitis  or  of  obstruc- 
tion in  eighty  per  cent,  of  the  cases  (Treves).  The  onset  is  sudden, 
the  pain  and  vomiting  very  severe,  the  constipation  is  complete, 
except  what  matter  may  come  from  the  intestine  below  the  disease, 
and  no  blood  is  passed. 

Gall-stones  large  enough  to  cause  obstruction  are  very  rare.  The 
history  of  previous  ones  passed  will  be  of  great  help,  as  will  also  the 
history  of  previous  hepatic  colic,  or  acute  obstruction  relieving 
itself. 

In  chronic  cases  the  diagnosis  rests  between  intussusception  on 
the  one  hand,  and  stricture  of  the  intestine  (from  any  cause,  either 
within  the  gut  or  from  pressure  without),  fecal  impaction,  and  gall- 
stone on  the  other. 

Stricture  may  be  detected  by  the  use  of  a  bougie  ;  failing  this, 
a  cancerous  mass  may  be  felt,  and  the  history  will  point  to  long- 
standing ulceration  with  the  usual  symptoms.  A  tumor  pressing 
upon  the  gut  can  often  be  made  out  by  careful  examination,  espe- 
cially through  vagina  or  rectum.  Fecal  impaction  may  be  felt 
through  either  the  rectum  or  abdominal  wall,  and  the  tumor  is 
generally  characteristic.  A  gall-stone  passing  slowly  along  the 
small  intestine,    causing    a   chronic  obstruction,   must  be  diagnos- 


INTUSSUSCEPTION".  187 

ticated  by  the  rules  given  for  detecting  it  when  causing  acute  ob- 
struction. 

A  peritonitis  from  perforation,  may  cause  all  of  the  symptoms  of 
an  acute  obstruction.  The  points  in  the  differential  diagnosis  are  as 
follows  :  in  peritonitis  the  vomiting  seldom  becomes  fecal,  but  re- 
mains bilious  to  the  end ;  the  constipation  is  less  marked,  and  the 
patient  generally  passes  gas  and  liquid  faeces  or  small  quantities  of 
solid  matter ;  the  tympanites  is  also  less  marked,  and  the  coils  of 
intestine  are  less  pronounced  ;  the  pain  begins  with  great  severity  at 
one  point,  and  extends  over  the  whole  abdomen  (the  same  thing  may 
happen  in  acute  obstruction,  but  in  such  cases  the  other  symptoms 
— fecal  vomiting,  absolute  constipation,  absence  of  the  passage  of 
gasper  anuvi — are  all  equally  severe,  while  in  peritonitis  they  do  not 
correspond  in  severity  with  the  intensity  of  the  pain)  ;  the  tempera- 
ture is  elevated  in  peritonitis,  and  normal,  or  even  less  than  normal, 
in  obstruction. 

It  will  thus  be  seen  that  the  differential  diagnosis  is  shrouded  in 
difllculty,  and  that  the  difficulty  is  rather  greater  in  a  case  of  chronic 
than  of  acute  obstruction.  A  well-marked  case  of  invagination, 
whether  acute  or  chronic,  is,  however,  the  easiest  of  all  the  forms  of 
occlusion  to  distinguish,  and  the  diagnosis  can  generally  be  made 
with  sufficient  approach  to  certainty  to  guide  the  surgeon  in  the 
selection  of  his  plan  of  treatment. 

Treatment  of  Intussusception. 

It  is  evident  that  the  treatment  of  the  conditions  we  have 
been  describing  must  differ  in  every  particular  from  that  of  those 
previously  described.  When  the  invagination  has  occurred  in  the 
rectum  —  that  is,  when  the  upper  part  of  the  rectum  has  become 
telescoped  into  the  lower  and  has  appeared  as  a  prolapsed  mass  out- 
side of  the  anus — the  case  may  still  be  relievable  by  the  methods  of 
reduction  and  taxis.  The  mass  must  be  replaced  by  a  process  ex- 
actly the  reverse  of  the  one  by  which  it  came  down,  the  most  depend- 
ent portion  being  first  carried  into  the  body  and  the  entanglement 
unfolded  in  this  way.  In  a  child,  with  the  assistance  of  anaesthesia, 
the  inverted  position,  and  gentle  manipulation  with  the  fingers,  or 


188  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

possibly  with  a  soft  bougie,  this  may  sometimes  be  accomplished 
where  the  point  of  constriction  is  low  down  near  the  anus. 

In  cases,  whether  of  adults  or  children,  where  the  constriction  is 
still  higher  in  the  intestine,  and  manipulation  with  the  hand  or 
bougie  is  out  of  the  question,  various  other  mechanical  means  may 
be  tried  with  a  prospect  of  success.  These  consist  in  applying  indirect 
pressure  to  the  invaginated  portion  and  to  the  constricting  part  by 
means  of  copius  injections  of  water  or  hydrogen  gas. 

With  regard  to  laparotomy  a  distinction  must  again  be  made 
between  children  and  adults.  In  children  the  disease  runs  an  acute 
course,  often  fatal  in  forty-eight  hours,  and  what  is  to  be  done  must 
be  done  as  soon  as  possible.  If,  therefore,  insufflation  or  injections 
fail  after  a  fair  trial,  nothing  remains  but  to  open  the  abdomen.  It 
is  useless  to  hope  for  spontaneous  redaction  or  gangrenous  separa- 
tion in  a  child.  Quoting  Treves  once  more,  spontaneous  elimination 
occurs  in  only  two  per  cent,  of  cases  during  the  first  year  of  life,  in 
only  six  per  cent,  between  the  ages  of  two  and  five,  and  forty  per 
cent,  of  all  cases  of  spontaneous  elimination  are  subsequently  fatal. 

Laparotomy  in  a  young  child  holds  out  a  fair  chance  of  success, 
and  the  earlier  it  is  done  the  better  the  prospect. 

On  this  point  Wiggins' s  study  of  one  hundred  and  three  collected 
cases  gives  much  valuable  information. 

Of  these  nearly  fifty  per  cent,  occurred  during  the  fourth,  fifth, 
and  sixth  months  in  nearly  equal  proportions,  and  eighty-nine  per 
cent,  were  of  the  ileocsecal  variety.  Cure  by  sloughing  was  met  with 
twice.  Thirty-nine  of  the  cases  were  treated  only  by  means  of  ene- 
mata  or  inflation,  or  both.  Of  these  sixteen,  or  forty-one  per  cent., 
recovered.  The  average  hour  after  the  onset  when  the  treatment  was 
begun  was  the  forty-first.  The  average  age  of  the  twenty-three  cases 
which  terminated  fatally  was  about  five  months.  The  average  hour 
following  the  onset  when  treatment  was  begun  was  the  sixty-ninth. 
"In  several  cases  collapse  followed  the  administration  of  the  enema, 
and  in  nearly  all  cases  there  is  the  same  story  of  the  inefficiency 
and  uncertainty  of  the  method,  the  tumor  disappearing  only  to  return 
after  a  short  interval,  and  the  treatment  repeated  again  and  again, 
the  occasional  repeated  administration  of  chloroform,  with  alter- 
nating injections  of    air  or  water,    combined  with    massage,   often 


INTUSSUSCEPTION".  189 

roughly  applied,  till  finally  death  mercifully  came  to  the  infant's 
relief." 

"  The  history  of  the  treatment  of  infantile  intussusception  by  the 
method  of  intestinal  distention,  by  either  air  or  water,  as  evidenced 
by  the  testimony  which  has  been  presented,  is  certainly  a  dark  page 
in  that  of  our  science.  It  is  the  story  of  empirical  rather  than  scien- 
tific endeavor — one  of  hope  deferred,  of  uncertainty,  of  prolonged 
torture,  none  the  less  cruel  because  it  was  performed  in  all  kindness, 
and  was  generally  considered  to  be  the  gentlest  method  of  dealing 
with  the  disorder,  and  finally  of  a  mortality  of  seventy-five  per  cent, 
of  disaster," 

Laparotomy  was  performed  in  this  group  of  cases  sixty-four  times, 
resulting  successfully  in  32.8  per  cent.  The  average  hour  from  onset 
to  time  of  operation  was  the  forty-fourth.  The  average  age  was  six 
and  one-half  months. 

"If  we  count  only  operations  successful  and  unsuccessful  that 
have  been  performed  since  the  perfected  technique  of  abdominal 
surgery  has  become  generally  known — say  since  1889 — and  throwing 
out  the  cases  in  which  the  operation  has  not  been  completed,  the 
bowel  incised  or  excised,  we  have  a  total  of  eighteen  cases,  of  which 
fourteen  were  successful  and  four  unsuccessful,  giving  a  still  lower 
percentage  of  mortality  of  22.2  per  cent.,  which  the  writer  believes  is 
a  fair  estimate  of  the  risk  to-day  of  abdominal  section  performed  on 
a  young  infant  for  the  relief  of  this  disorder,  if  performed  within  the 
first  forty-eight  hours  of  the  onset." 

In  Wiggins' s  tables  there  is  one  successful  case  of  laparotomy  at 
the  age  of  three  months  hy  Howit.  I  have,  happily,  since  those 
tables  were  published,  been  able  to  add  another  of  the  same  age,  and 
these  two  are,  as  far  as  I  know,  the  only  ones  recorded.  My  own 
case  was  seen  within  a  few  hours  of  the  onset  of  the  trouble,  and  the 
diagnosis  was  clear  from  the  presence  of  the  mass  in  the  rectum.  No 
time  was  spent  in  attempts  at  reduction  and  the  abdomen  was  opened 
immediately.  To  this  fact  the  good  result  is  chiefly  to  be  attrib- 
uted. 

In  adults  the  operation  is  as  positively  called  for  as  in  children. 
The  mortality  of  the  disease  is  seventy  per  cent.,  and  this  has  been 
greatly  diminished  by  early  operation.     The  cases  which  recover  are 


190 


SURGERY   OF   THE   RECTUM   AND   PELVIS. 


those  in  which  spontaneous  reduction  occurs,  and  not  those  which 
become  chronic,  or  in  which  gangrenous  elimination  takes  place,  for 
both  of  these  generally  end  fatally  after  a  time. 

After  opening  the  abdomen  the  first  attempt  should  be  toward  re- 
ducing the  invagination.  This  will  almost  always  be  impossible  by 
any  amount  of  traction  from  above,  even  in  cases  where  it  can  easily 
be  effected  by  pressure  on  the  apex  from  below.  The  gut  should  be 
encircled  by  the  fingers  of  one  hand  just  below  the  apex,  while  the 
whole  tumor  is  held  in  the  other,  and  gentle  pressure  used  to  express 


Pig.  115. 
Maunsell's  Operation  Applied  to  Intussusception. 


the  contained  from  the  ensheathing  portion  from  below  upward.  If 
the  conditions  are  such  as  to  render  reduction  possible,  there  will 
probably  be  no  gangrenous  gut  and  the  abdomen  should  be  closed  as 
rapidly  as  possible,  and  every  effort  directed  toward  overcoming  the 
shock  which  is  always  present. 

In  case  of  failure  to  effect  reduction,  there  are  several  courses  to 
be  considered.  An  artificial  anus  may  be  formed  in  healthy  gut 
above  the  disease,  but  this  will,  in  many  cases,  carry  with  it  inevita- 
ble death  from  inanition,  if  the  condition  be  allowed  to  remain.  This 
plan  of  treatment  is  therefore  only  a  temporary  expedient  for  carrj^- 


INTUSSUSCEPTIOISr.  191 

ing  the  patient  over  the  shock  of  the  condition  and  allowing  nature 
to  complete  the  elimination  of  the  diseased  parts,  and  involves  alwaj^s 
the  idea  of  subsequent  operation,  should  the  patient  survive. 

Maunsell's  plan  of  end  to  end  suture  may  be  used  after  opening 
the  sheath  and  cutting  off  the  contained  gut  as  shown  in  Fig.  115. 
It  would  seem,  however,  that  there  might  often  be  difficulty  in  bring- 
ing the  points  AA  far  enough  through  the  incision  CC  without  vio- 
lence and  laceration  of  the  mesentery,  to  allow  of  suturing. 

If  for  any  reason  Maunsell's  operation  is  impracticable,  an  or- 
dinary end  to  end  anastomosis  after  resection  of  the  tumor  may  be 
done,  or  a  lateral  anastomosis,  preferably  by  Abbe's  method. 

The  operation  of  excision  with  any  form  of  anastomosis,  though 
it  may  be  successful  in  an  adult,  holds  out  little  hope  for  a  child  with 
acute  intussusception.  The  operation  is  long  and  severe,  the  shock 
necessarily  great,  and  the  patient  in  no  condition  to  withstand  so 
radical  a  measure.  There  is,  as  far  as  I  know,  no  successful  case 
under  one  year  of  age. 

Treatment  of  Rectal  Hernia. 

The  treatment  of  a  true  case  of  rectal  hernia  still  remains  to  be 
mentioned.  The  radical  treatment  for  the  uncomplicated  condition 
consists  in  oblation  of  the  sac  as  already  described.  When  the  her- 
nia has  become  inflamed  the  treatment  should  be  directed  toward  re- 
ducing the  inflammation  by  rest,  local  antiphlogistic  measures,  and 
opium.  If  reduction  be  possible  it  may  be  performed.  If  reduction 
be  impossible  and  the  hernia  acutely  inflamed,  it  must  be  treated,  as 
a  strangulated  hernia  elsewhere  would  be,  by  operation  tending  to 
divide  the  constriction  causing  the  strangulation.  If  the  constriction 
seems  to  be  at  the  sphincter  ani,  it  can  easily  be  overcome  by  stretch- 
ing, without  a  cutting  operation  and  without  opening  the  peritoneum. 
If  it  be  at  the  neck  of  the  sac  the  same  manoeuvre  may  be  possible. 
Various  methods  of  subcutaneous  section  of  the  constriction  have 
been  recommended,  but  none  of  them  rest  upon  any  clinical  expe- 
rience. 

In  case  a  rupture  of  the  sac  or  of  the  rectum  has  alread}''  occurred 
and  the  intestines  have  escaped  through  the  rent,  there  is  still  much 
for  the  surgeon  to  do,  although  the  prognosis  is  almost  hopeless. 


192  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

Smith's  case  recovered,  but  here  the  accident  occurred  directly  under 
the  eye  of  the  operator,  and  the  bowel  was  immediately  replaced 
before  it  had  been  long  exposed  to  the  air  or  had  become  inflamed. 

It  will  be  noticed  that  in  every  case  but  one  where  the  rupture 
has  been  due  to  violence,  death  has  been  the  consequence  ;  and  also 
that  in  every  case  but  that  one  (Nedham's)  an  effort  has  been  made 
at  reduction,  even  though  laparotomy  were  necessary  for  its  accom- 
plishment. 

There  is  no  doubt  that  the  first  duty  of  the  surgeon  is  to  replace 
the  mass  within  the  abdomen  after  cleansing  it,  and  this  is  seldom  an 
easy  matter.  The  amount  protruded  is  often  enormous  ;  it  is  also 
generally  distended  with  gas  and  fseces ;  the  rent  through  which  it 
must  be  returned  is  more  or  less  concealed  from  vision  and  touch; 
and  the  intestines  constantly  tend  to  pass  upward  into  the  rectum 
above  the  rent  rather  than  into  the  peritoneal  cavity.  A  part  of  the 
contents  of  the  bowel  may  be  pressed  back  into  the  abdomen  by 
gentle  manipulation,  and  punctures  may  be  made  to  evacuate  the 
remainder.  The  reduction,  however,  has  seldom  been  completely  ac- 
complished without  recourse  to  laparotomy. 

After  the  reduction  has  been  accomplished  the  rent  must  be 
closed  by  sutures — in  itself  an  exceedingly  difficult  task,  but  one 
which  is  rendered  easier  by  the  abdominal  wound  already  made,  and 
which  might  be  still  further  facilitated  by  a  posterior  enlargement  of 
the  anus  by  incision.  After  the  rectal  wound  has  been  sutured  the 
abdominal  one  may  be  closed,  a  tampon  applied  to  the  rectum,  and 
opium  with  fluid  diet  administered  ;  but  the  chances  of  a  favorable 
termination  of  the  case  are  very  slight,  the  patient  generally  dying 
of  collapse  or  peritonitis. 

If  the  protruded  bowel  be  greatly  inflamed,  and  approaching 
gangrene  in  appearance,  the  surgeon  must  choose  between  replacing 
it  and  cutting  it  off.  These  cases  must  be  studied  and  treated  in  the 
light  of  the  results  of  intestinal  resection  and  the  establishment  of 
intestinal  anastomosis. 

The  case  last  reported  by  Quenu  is  the  first  in  which  an  effort  has 
been  made  to  suture  the  rent  in  the  prolapsus,  through  which  the 
small  gut  has  escaped,  by  means  of  a  laparotomy.  The  operation, 
in  spite  of  this  failure,  still  seems  feasible. 


CHAPTER  XII. 

NON-MALIGNANT   GROWTHS   OF   THE    RECTUM   AND   ANUS. 


Under  this  head  will  be  included  polypus,  vegetations,  condylo- 
mata, benign  fungus,  fibromata,  lipomata,  and  the  various  forms  of 

cysts. 

Polypus. 

A  polypus   may  be   defined   as   a  benign   tumor  composed  of 
one  or  more  of  the  normal   elements  of   the  wall  of  the  rectum ; 


Fig.  116. 
Villous  Polypus. 

an  hypertrophy  either  of   the  mucous  membrane  or  of  the   sub- 
mucous  connective   tissue,   or  both.      Those   which   are  composed 

13 


.194  SUEGERY  OF  THE  RECTUM  AND  PELVIS. 

of  the  elements  of  the  mucous  membrane  are  known  and  generally 
spoken  of  as  "soft  "  polypi ;  while  those  into  which  the  submucous 
connective   tissue   enters  are  known  as  the  "hard"  or  fibrous.     In 


many  works  the  former  class  are  spoken  of  as  the  polypi  of  child- 
hood, and  the  latter  as  those  of  adult  age — a  classification  of  little 
practical  value. 

The  mucous  membrane,  as  has  been  shown,  is  composed  of  villi, 
of  the  follicles  of  Lieberkuhn  or  tubular  glands,  and  of  occasional 
closed  or  solitary  follicles.  A  polypus  composed  of  an  hypertrophy 
of  the  villi  is  well  represented  in  Fig.  116. 

A  polypus  of  this  variety  may  reach  the  size  of  a  pigeon's  egg; 
it  is  soft  to  tlie  feel,  and  has  a  shaggy  or  cauliflower  surface.  On 
section  the  cut  surface  is  of  grayish-red  color,  the  substance  of  the 
growth  homogeneous,  and  the  fluid  which  may  be  forced  from  it  by 
pressure  will  be  found  to  be  full  of  cylindrical  epithelium.     A  micro- 


NON-MALIGNANT    GROWTHS   OF   THE   RECTUM   AND    ANUS.        195 

scopic  examination  shows  it  to  be  composed  of  long,  fine  papillae 
bifurcated  at  their  extremities  and  covered  by  cylindrical  epi- 
thelium. 

Villous  Polypus. 

It  is  a  question  whether  this  form  of  growth  should  be  classified 
with  the  polypi  already  described  or  with  the  warty  growths  whose 


Fig.  lis. 
Glandular  Polypus. 


description  is  to  follow.  It  consists  of  a  hypertrophy  both  of  the 
villi  and  of  the  follicles  of  Lieberkuhn,  with  a  centre  of  connective 
tissue  and  generous  vascul^-r  supply. 

These  tumors  are  very  rare  ;  they  have  the  feel  of  a  large,  warty 
polypus  with  cauliflower  surface,  are  of  red  color,  bleed  easily,  and 
are  of  relatively  slow  growth.  They  adhere  to  the  wall  of  the  rectum 
by  a  pedicle,  sometimes  composed  chiefly  of  mucous  membrane,  and 
at  others  large,  short,  and  fleshy. 

The  pedicle  may  be  absent,  and  the  growth  will  vary  in  structure 
according  to  the  proportion  of  its  different  elements.  It  may  reach 
the  size  of  an  orange.  It  is  found  only  in  adults  or  in  old  persons, 
and  the  symptoms  are  the  same  as  those  caused  by  other  polypi — viz., 


196 


SUEGEEY  OF  THE  RECTUM  AND  PELVIS. 


discharge  and  hemorrhage,  but  the  hemorrhage  is  not  a  constant 
symptom,  and  varies  greatly  in  frequency  and  amount  in  different 
cases. 

Glandular  Polypus. 

The  adenomatous  polypi,  or  those  developed  from  the  glands 
of  the  mucous  membrane,  are  well  shown  in  Fig.  118. 

These  may  be  due  either  to  an  hypertrophy  of  the  follicles  of 
Lieberkuhn  or  of  the  closed  follicles.     Tlie}^  occur  most  frequently  in 


Fig.  119. 
Section  of  Glandular  Polypus. 

young  persons ;  are  generally  of  the  size  of  a  small  plum,  rarely 
reach  that  of  a  pear,  and  yet  Esmarch  reports  one  weighing  four 
pounds.  They  are  very  vascular  tumors,  and  therefore  of  reddish 
color.  They  are  sometimes  smooth  on  the  surface,  but  oftener  mam- 
millated,  like  a  strawberry,  and  are  attached  by  a  pedicle,  most  often 
to  the  posterior  wall,  but  occasionally  to  the  sides  of  the  rectum, 
and  at  a  point  generally  within  reach  of  the  finger,  but  sometimes 
higher  up.  They  may,  indeed,  occur  anywhere  along  the  large  intes- 
tine, as  Mgh  up  as  the  ileocsecal  valve. 


NOiSr-MALIGNANT    GROWTHS   OF   THE   EECTUM    AND   AjSTUS. 


197 


The  pedicle  is  generally  large  and  short,  and  not  long  and  slender 
as  in  the  case  of  the  fibrous  polypi  soon  to  be  described  ;  but  there 
are  frequent  exceptions  to  this  rule,  and  these  tumors  will  some- 
times be  spontaneously  expelled  by  rupture  of  the  slender  pedicle  in 
defecation. 

Polypi  which  consists  of  an  hypertrophy  of  the  closed  follicles  of 
the  rectum  are  often  found  in  considerable  numbers.  Fochier  removed 


Fig.  120. 
Adeiio  -papilloma. 

severel  hundred  of  them  from  a  patient  aged  eighteen,  and  Richet 
from  sixty  to  a  hundred  in  a  man  aged  twenty-one.  Yan  Buren 
speaks  of  the  same  condition,  adopting  Broca's  name  of  ^'polyaden- 
omata."  To  this  variety  of  polypus  belong  also  certain  cysts  (closed 
follicles)  distended  hj  viscid  and  transparent  fluid. 

On  section  these  adenomatous  polypi  are  found  to  contain  much 
viscid  fluid,  full  of  cylindrical  epithelium  and  rudimentary  glandular 
tubes.     Under  the  microscope  a  vascular  stroma  of  connective  tissue 


198 


SUKGERY    OF   THE   EECTUM   AND    PELVIS. 


will  be  found,  in  which  are  enlarged  glandular  tubes,  sometimes 
branching  at  their  extremities,  and  also  cystoid  spaces  filled  with 
reddish  viscid  fluid. 

The  microscopic  appearances  of  a  section  of  such  a  polypus  are 
shown  in  Fig.  119. 

The  following  is  the  report  of  the  microscopic  examination  of 
such  a  tumor  removed  in  my  own  practice : 

"I  find  the  growth  to  be  an  adeno  papilloma.     Its  surface  is  cov- 
ered with  thickly  set,  delicate,  rarely  branching  papillse  which  are 
composed  of  connective  tissue  and  blood-vessels  and  are  covered  by 
high,  cylindrical  epithelial  cells.     In  the  deeper  parts  are  branching- 
tubes  lined  with  cylindrical  epithelium.     The 
stroma  of  the  tumor  is  rich  in  young  cells 
and  highly  vascular. 

"This  tumor  is  usually  ranked  as  non- 
malignant,  but  it  seems  to  lie  on  the  border- 
land between  the  benign  and  malignant 
growths.  It  often  returns  upon  removal,  but 
rarely  produces  metastases. 

"William  H.  Welch." 


Fibrous  Polypus. 

The  hard  or  fibrous  polypus,  which  is 
composed  primarily  of  the  elements  of  the 
submucous  connective  tissue,  is  much  rarer 
than  the  soft  variety,  and  is  most  commonly 
found  in  adults,  where  it  may  be  isolated  or 
multiple.  It  is  chiefly  composed  of  flbrous 
tissue,  and  resembles  the  uterine  fibroid  ;  but 
it  may  contain  both  muscular  and  glandular 
elements.  When  the  glandular  elements  are 
filled  with  fluid  which  resembles  glue,  these 
tumors  have  been  known  as  colloid ;  and 
when  cysts  are  found  filled  with  jelly-like 
substance,  the  name  myxoma  has  also  been  applied. 

These   hard   or   fibrous   polypi    vary  greatly  in  their  degrees  of 


Fig.  121. 
Adeno-papilloma. 


NON-MALIGN"A]SrT    GROWTHS   OF   THE   RECTUM    AND    ANUS. 


199 


hardness  to  the  feel,  according  to  their  tiirgescence  and  their  compo- 
sition. They  may  creak  under  the  knife  on  section,  and  look  very 
much  like  hypertrophied  and  oedematous  skin,  or  they  may  resemble 
the  better-known  nasal  polypus  in  their  consistence. 

The  connective-tissue  fibres  are  generally  irregularly  disposed, 
and  cross  each  other  in  every  direction,  though  a  regular  stratifica- 
tion, such  as  is  seen  in  uterine  myxomata,  may  be  present.  When 
seen  in  the  rectum  before  removal,  the  surface  is  generally  red  from 
their  vascularity  ;  but  after  removal  they  are  pale,  and  generally 
smooth,  though  sometimes  uneven  and  irregular  in  surface,  and  cov- 
ered with  hypertrophied  papillae.  The  mucous  membrane  is  gener- 
ally easily  stripped  off,  though  if  there  has  been  local  inflammatory 
irritation  it  may  be  firmly  attached.  The  vascular  supply  is  abund- 
ant, and  distributed  both  to  the  substance  and  surface  of  the  tumor. 
This  accounts  for  their  rapid  development. 


Fig.  132. 
Fibrous  Polypi. 


The  pedicle  is  generally  very  slight,  and  is  formed  mechanically 
by  the  traction  of  the  growth  on  the  mucous  membrane  beneath 
which  it  is  located.  It  is  composed,  as  in  the  soft  variety,  simply  of 
mucous  membrane  and  blood-vessels.  There  may,  however,  in  a 
case  where  the  pedicle  has  been  formed  by  traction  upon  and  pro- 
lapse of  all  the  coats  of  the  bowel  by  a  tumor  located  primarily 


200  SUKGEEY   OF   THE   EECTUM   AND   PELVIS. 

above  the  reflexion  of  the  peritoneum,  be  a  peritoneal  cul-de-sac 
within  the  pedicle. 

If  left  to  its  natural  course,  the  pedicle  gradually  becomes  longer 
and  more  slender,  and  finally  ruptures  in  the  act  of  defecation,  and 
in  this  way  a  patient  may  relieve  himself  of  the  growth. 

These  tumors  are  benign  in  character,  and  when  once  removed  do 
not  generally  return  at  the  same  point.  They  maj^,  however,  recur, 
if  not  at  the  same  point,  at  one  very  near  it,  and  the  same  patient 
may  be  relieved  of  a  succession  of  them. 


Fig.  123. 
Fibrous  Polypus  with  Attachment  to  Mucous  Membrane. 

Fig.  123  represents  one  of  these  tumors  removed  from  a  middle- 
aged  man,  in  which  case  a  diagnosis  of  malignant  disease  had  been 
made. 

Symptoms. — A  rectal  polypus  may  exist  for  many  years  and  give 
no  signs  of  its  presence.  The  two  chief  symptoms  which  it  is  apt  to 
excite  are  hemorrhage  and  discharge.  The  hemorrhage  may  be  a  daily 
occurrence,  or  may  be  present  only  at  long  intervals,  and  it  may  vary 
in  amount  from  a  few  drops  to  a  quantity  which  shall  cause  grave 
disturbance  and  alarm.  When  the  mucous  membrane  covering  the 
tumor  has  once  become  ulcerated,  the  hemorrhage  will  be  frequent 
and  the  discharge  will  be  more  or  less  fetid.  The  vessels  are  apt  to 
bleed  freely  when  opened,  because  of  their  being  embedded  in  fibrous 
tissue  and  of  their  inability  to  contract.  When  the  tumor  is  so  high 
and  the  pedicle  so  short  as  to  be  beyond  the  grasp  of  the  sphincter, 
there  is  no  suffering,  unless  the  irritation  of  the  growth  has  set  up  a 


NON-MALIGNANT    GROWTHS   OF   THE    RECTUM   AND    ANUS.         201 

catarrhal  proctitis  ;  but  after  prolapse  once  begins  to  take  place  the 
suffering  may  be  very  severe.  The  sphincter  may  become  dilated  and 
relaxed,  or  the  pedicle  may  be  firmly  grasped  by  it  after  the  act  of 
defecation,  and  a  cure  may  result  from  the  strangulation  thus  caused. 

The  discharge  from  the  rectum  vv^hich  a  polypus  may  cause  is  some- 
times extreme  in  amount  and  constant,  escaping  not  only  at  the  time 
of  defecation,  but  at  frequent  intervals  between,  and  being  of  an  ex- 
cessively fetid  character.  This  discharge  may,  by  its  irritating 
qualities,  cause  secondary  congestion  of  the  rectal  mucous  membrane, 
erosions  around  the  anus,  vegetations,  constant  diarrhoea,  and 
tenesmus  ;  and,  joined  with  the  loss  of  blood,  the  condition  of  the 
patient  may  be  easily  mistaken  for  that  of  chronic  dysentery  or  even 
malignant  disease. 

Hemorrhage  from  the  rectum  in  a  child,  with  or  without  pain  on 
defecation,  generally  means  polypus  ;  and  it  often  means  the  same  in 
an  adult,  though  it  will  oftener  indicate  hemorrhoids.  The  secondary 
symptoms,  which  seemed  to  point  to  dysentery,  must  never  cause  the 
original  disease  to  be  overlooked.  There  is,  in  fact,  but  little  diffi- 
culty in  the  diagnosis  of  a  polypus  in  the  vast  majority  of  cases  ;  but 
once  in  a  while,  where  the  attachment  is  broad  and  the  pedicle  not 
well  marked,  the  question  of  benign  or  malignant  growth  may  arise 
and  be  difficult  to  solve  except  by  the  microscope.  ■ 

In  the  chapter  on  Cancer  attention  will  be  called  to  the  fact  that 
the  distinction  between  epithelioma  and  a  benign  polypus  of  the 
adenoid  variety  cannot  always  be  made  by  the  microscopic  exami- 
nation ;  and  we  here  emphasize  the  fact  that  the  diagnosis  must  rest 
toth  upon  the  clinical  history  and  gross  appearances,  and  upon  his- 
tological investigation  of  the  growth  when  removed.  In  children 
malignant  disease  is  so  rare  that  the  chances  are  greatly  in  favor  of 
benignity.  Malignant  growths,  moreover,  do  not  tend  to  spontaneous 
extrusion  and  are  not  pedunculated,  and  the  presence  of  a  pedicle  is 
therefore  greatly  in  favor  of  benignity.  But  given  an  adult  with  an 
adenoid  polypus  which  has  ulcerated  and  which  is  not  pedunculated, 
and  the  diagnosis  between  it  and  malignant  disease  may  be  impossible, 
either  by  the  microscope  or  the  clinical  history  :  for  the  ulcerated 
and  bleeding  tumor  may  cause  a  wasting  and  cachexia  which  strongly 
resembles  cancer.     A  soft  polypus  may  also  be  mistaken  for  an  in- 


202  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

ternal  hemorrhoid  when  no  pedicle  is  present,  but  the  point  of  attach- 
ment is  different  in  the  two  cases. 

Treatment. — Tlie  treatment  of  polypi  is  generally  a  simple  matter, 
and  consists  in  their  extirpation,  after  which  they  rarely  return. 
There  are  two  dangers  to  be  considered  :  the  first  is  that  the  pedicle, 
when  a  pedicle  exists,  may  contain  large  vessels  ;  the  other  is  that  it 
may  contain  peritoneum.  The  extirpation  of  a  polypus  which  has 
come  down  from  its  attachment  in  the  sigmoid  flexure,  has  been  fol- 
lowed by  death  from  wounding  the  peritoneum,  at  the  hands  of  no 
less  a  surgeon  than  Broca.  Where  the  pedicle  is  long  and  slender, 
the  polypus  may  generally  be  twisted  off  by  simple  torsion  without 
danger.  It  is  generally  safer,  however,  first  to  apply  a  ligature  and 
then  cut  away  the  tumor.  Should  there  be  no  pedicle,  the  mass  must 
be  extirpated  as  any  tumor  would  be,  and  the  hemorrhage  which 
occurs  must  be  treated  upon  general  surgical  principles. 


Vegetations. 

These  growths,  known  also  by  the  names  of  warts  and  papil- 
lomata,  may  be  defined  histologically  as  an  hypertrophy  of  the 
papillary  layer  of  the  skin,  and  of  the  papillary  layer  only.  They 
are  composed  of  the  connective  tissue,  the  epithelial  covering,  and 
the  blood-vessels,  which,  in  their  natural  quantities,  form  the  papilla 
of  the  derma. 

The  gross  appearances  of  these  warty  growths  are  represented  in 
Fig.  124. 

Under  the  influence  of  any  of  the  exciting  causes  which  will  soon 
be  mentioned,  little  tumors  resembling  ordinary  warts  appear,  and 
grow  rapidly  till  they  reach  two  or  three  millimetres  in  size.  The  ex- 
tremity of  the  tumor  shows  a  decided  tendency  to  branching  and 
bifurcation,  and  when  there  are  many  of  them  their  branching  ex- 
tremities may  fuse  together  and  form  a  large  flat  tumor,  which  will 
be  attached  to  the  skin,  however,  by  numerous  little  pedicles,  so  that, 
if  shaved  off,  the  skin  will  not  be  wounded  except  in  numerous 
small  points  where  the  pedicles  have  had  each  its  independent  attach- 
ment. 


NON-MALIGNANT    GROWTHS   OF   THE   RECTUM   AND   ANUS. 


203 


When  the.  wart  is  isolated  it  is  dry,  but  when  several  are  united 
they  become  macerated  in  the  secretion  of  the  part,  which  decom- 
poses between  them  and  gives  rise  to  inflammatory  phenomena.  The 
tumor  then  becomes  moist  and  fetid,  and  all  the  adjacent  parts  be- 
come irritated.     According  to  the  size  of  the  growths,  the  condition 


Fig.  124. 
Non-syphilitic  vegetations. 

of  the  patient,  the  abundance  of  the  secretions,  and  the  irritation  to 
which  they  are  originally  due,  these  vegetations  take  on  various 
shapes,  and  have  been  described  as  cock's-combs,  cauliflower  ex- 
crescences, etc.,  etc.;  but  the  elementary  structure  of  them  all  is 
the  same  — an  hypertrophy  and  branching  of  the  papilla?  of  the 
derma. 


204  SURGEKY   OF   THE   RECTUM   AND   PELVIS. 

On  placing  a  longitudinal  section  of  one  of  tliese  warts  under  the 
microscope  the  following  structures  will  be  seen.  In  the  centre,  a 
framework  of  connective  tissue  composed  of  a  prolongation  of  the 
papillary  bodies  of  the  derma  ;  in  the  centre  of  this,  a  vascular  loop  ; 
the  whole  covered  by  one  or  more  layers  of  epithelium,  the  form 
and  size  of  which  are  variable  and  depend  apparently  on  several  con- 
ditions, such  as  the  moisture  and  dryness  of  the  parts  and  the 
amount  of  pressure  to  which  the  growths  are  subject.  When  the 
connective  tissue  is  abundant  and  the  epithelial  layer  relatively  thin, 
the  vegetations  are  dry  and  hard.  When  the  conditions  are  reversed 
they  are  moist.  When  the  vascular  network  is  greatly  developed  the 
tumors  are  red  and  turgescent,  and  bleed  easily. 

These  vegetations  were  formerly  considered  as  proof  positive  of 
the  existence  of  syphilis,  and  even  of  sodomy,  and  were  treated  as 
such.  Molliere  relates  how,  at  the  time  of  Dionysius,  there  was  a 
special  hospital  at  Rome  for  the  treatment  of  these  growths  ;  and 
Dionysius  himself  tells  how  the  surgeons  spared  neither  the  iron  nor 
the  fire,  and  were  not  moved  to  pity  by  the  cries  of  the  patients,  in- 
asmuch as  this  disease  was  the  result  of  unnatural  intercourse  be- 
tween man  and  man. 

The  same  false  idea  has  lasted  until  the  present  time,  and  is  even 
now  far  from  unpopular  ;  and  yet  the  independence  of  these  growths 
upon  syphilis  is  beyond  question,  except  to  the  extent  that  Ruy 
syphilitic  sore  in  this  neighborhood  may,  by  the  irritation  of  its  dis- 
charge, cause  their  production.  They  owe  their  growth,  in  the  first 
place,  to  a  special  predisposition  to  the  formation  of  warty  growths 
on  various  parts  of  the  body  in  the  individual,  and  this  predisposi- 
tion is  assisted  by  the  presence  of  any  irritation  of  the  part.  Thus  the 
discharge  from  a  gonorrhoea  or  a  leucorrhcEa,  or  any  disease  of  the 
rectum  or  genitals  may  cause  them  to  grow,  and  they  may  appear  in 
persons  apparently  perfectly  healthy  and  cleanly.  Pregnancy  has 
an  undoubted  influence  upon  their  production,  and  they  sometimes 
disappear  spontaneously  after  delivery.  From  what  has  been  said  it 
is  evident  that  these  growths  are  neither  contagious  nor  inoculable, 
and  that  anti-syphilitic  treatment  can  be  of  no  avail. 

These  vegetations  may  occur  at  any  age  from  infancy  to  adult  life, 
though  they  generally  belong  to  the  latter  period.     They  may  vary 


NON-MALIGNANT    GROWTHS    OF   THE   EECTUM   AND   ANUS.         205 

in  size  and  number  from  a  single  enlarged  papilla  at  the  verge  of  the 
anus  to  a  mass  such  as  is  represented  in  the  plate,  and  which  weighs 
as  much  as  a  pound.  The  symptoms,  in  any  case,  will  vary  with 
their  size,  number,  location,  and  the  amount  of  the  secretion.  When 
they  grow  from  one  side  of  the  intergiuteal  fold,  and  are  large  enough 
to  press  with  their  moistened  surface  upon  the  corresponding  point 
of  the  opposite  side,  a  second  patch  may  be  developed  at  the  point 
of  contact.  The  irritation  from  any  other  source  would  have  the 
same  effect.  The  development  of  the  growths  ma}^  be  slow  or  rapid, 
and  when  the  tumors  are  of  large  size  the  patient  is  constantly 
troubled  by  the  feeling  of  a  foreign  body,  by  a  sanious  and  foul- 
smelling  discharge,  and  by  fresh  erosions  and  superficial  ulcers  in  the 
adjacent  parts.  Great  pain  in  defecation  ma}^  be  produced  by  a 
small  wart  situated  just  at  the  verge  of  the  anus,  and  such  a  little 
tumor  may  give  rise  to  all  the  characteristic  symptoms  of  a  painful 
fissure,  including  a  slight  discharge  and  an  occasional  drop  or  two 
of  blood.  They  are  not  very  infrequent  on  the  line  of  junction  of 
the  mucous  and  cutaneous  surfaces,  just  within  the  verge  of  the 
anus.  They  may  also  spring  entirely  from  the  mucous  membrane, 
above  the  sphincter,  though  they  are  generally  confined  to  the  first 
incli  of  the  canal,  and  in  such  cases  give  rise  to  a  much  more  ag- 
gravated train  of  symptoms  and  to  much  difiiculty  of  diagnosis. 
There  they  are  generally  smaller  and  harder  than  when  on  the  cuta- 
neous surface,  and  cause  a  serous  discharge,  which  may  be  so  pro- 
fuse as  to  escape  from  the  anus  between  the  acts  of  defecation,  and 
cause  much  suffering  from  pruritus  and  rectal  tenesmus. 

On  examination  in  such  a  case  the  mucous  membrane  will  be 
found  dry  and  glistening,  as  a  rule,  though  sometimes  there  may  be 
a  more  or  less  extensive  proctitis  ;  and  the  little,  hard,  tender,  warty 
excrescence,  which  is  the  cause  of  all  the  grave  train  of  symptoms 
and  of  so  much  suffering,  may  easily  escape  detection.  The  only 
treatment  for  such  a  condition  is  to  seize  the  little  tumor  with  the 
toothed  forceps,  and  excise  the  mucous  membrane  to  which  it  is  at- 
tached.    It  may,  however,  return  many  times. 

The  diagnosis  of  these  growths  is  not  generally  diflScult,  though 
care  is  necessary  when  they  are  small  and  located  within  the  grasp 
of  the  sphincters.     The  mistake  most  commonly  made  is  to  consider 


206  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

them  as  syphilitic  condylomata  ;  and,  indeed,  they  may  not  always 
be  easily  distinguishable  from  the  raised  mucous  patch  or  fiat  condy- 
loma which  is  a  manifestation  of  true  syphilis.  A  careful  examina- 
tion of  a  raised  mucous  patch  can  scarcely  fail,  however,  to  show  the 
difference  between  its  general  character  and  that  of  a  cauliflower 
growth  which  has  sprung  up  from  the  surface  like  a  shrub  and  is  at- 
tached to  it  by  numerous  little  pedicles.  The  two  may  exist  simul- 
taneously, the  wart  being  caused  by  the  irritation  of  the  discharge 
from  the  other.  There  is  little  danger  of  mistaking  these  vegetations 
for  malignant  growths,  though  they  have  been  known  to  assume  a 
semi-malignant,  epithelial  character,  and  to  return  frequently  after 
removal. 

The  surest,  most  rapid,  and  in  every  respect  most  satisfactory 
way  of  curing  these  vegetations  is  by  simple  excision  with  the  knife 
or  scissors.  The  ligature  is  often  inapplicable,  and  cauterization  is 
not  always  easy  to  limit  in  its  action.  The  growths  may,  however, 
often  be  induced  to  dry  and  shrink  up  by  applications  of  powdered 
alum  or  tannin,  and  by  washing  with  astringent  lotions,  such  as 
Labarraque's  solution. 

Condylomata. 

There  is  a  variety  of  mucous  patch  situated  upon  the  skin  near 
the  anus  to  which  the  name  condyloma  lata,  or  vegetating  condy- 
loma, can  alone  be  properly  applied  (Figs.  125  and  126). 

The  syphilitic  condyloma  first  manifests  itself  as  a  red  spot  and 
by  a  slight  effusion  beneath  the  epidermis,  which  is  soon  rubbed  off 
by  friction,  exposing  a  raw  surface,  generally  covered  by  a  grayish 
pellicle.  This  surface  is  subsequently  elevated  by  an  upward 
growth,  and  by  branching  off  the  papillae,  with  formation  of  connect- 
ive tissue  and  dilatation  of  the  blood-vessels.  Where  this  develop- 
ment of  the  papillae  has  reached  a  considerable  extent,  the  cauli- 
flower appearance  is  the  result,  and  what  was  at  first  a  simple 
mucous  patch  may  become  a  large  pedunculated  wart,  surrounded  by 
other  vegetations  which  have  sprung  up  around  the  original  lesion, 
and  which  are  due  to  the  irritation  of  its  presence. 

It  may  be  impossible  to  distinguish  this  form  of  syphilis  from 
the  simple  vegetation  already  described,  except  by  the  history,  the 


NON-MALIGNANT    GROWTHS   OF  THE    RECTUM   AND   ANUS.         207 

fact  of  its  infectiousness,  and  tlie  results  of  treatment.  Under  the 
microscope  both  are  composed  of  an  hypertrophy  of  the  papillae  of 
the  derma.  It  ought  not,  however,  to  be  difficult  to  distinguish  be- 
tween this  syphilitic  mucous  patch,  to  which  we  here  limit  the  name 
of  condyloma,  and  the  simple  hypertrophy  of  the  skin,  such  as  is 
seen  at  the  site  of  an  old  external  pile. 

This  loose  and  undefined  use  of  the  word  condyloma  is  much  to 
be  regretted.  It  is  used  here  to  denote  only  one  form  of  growth,  the 
syphilitic  mucous  patch. 


^^^piiiii^BW'^^^^^^^^^ 


Fig.  125. 
Syphilitic  Condylomata. 

There  are  frequently  seen  around  the  anus  growths  of  skin  which 
are  attached  by  a  broad  base,  are  pinkish  in  color,  soft,  fleshy,  glis- 
tening, moist,  and  irregular  in  shape,  flattened  where  two  are  pressed 
together,  or  where  one  is  subjected  to  the  pressure  of  the  buttocks, 
and  which  generally  give  out  a  slight  secretion. 

They  generally  have  one  of  the  radiating  folds  of  the  anus  as 
their  point  of  origin,  and  they  differ  from  the  class  of  vegetations 
last  described  in  that  they  consist  of  an  hypertrophy  of  the  whole 
thickness  of  the  skin,  and  not  alone  of  the  papillae.     The  epithelial 


208 


SURGERY    OF   THE    RECTUM    AND    PELVIS. 


element  in  tliem  is  not  as  marked  as  in  the  warts,  and  the  blood-ves- 
sels are  also  less  developed.  They  are  merely  the  result  of  a  local- 
ized chronic  inflammation  and  thickening  of  the  skin,  and  often 
follow  an  external  hemorrhoid  or  any  local  irritation  such  as  has 
been  spoken  of  in  connection  with  vegetations.  They  are  generally 
isolated  and  few  in  number  ;  but  it  may  happen  that  after  the  irrita- 
tion, to  which  they  owe  their  origin,  has  ceased,  the  growth  may  con- 
tinue, becoming  harder  and  more  movable,  and  resembling  a  true 
fibroma.     Such  a  hard  tumor  may,  under  sufficient  irritation,  take 


Fig.  126. 
Syphilitic  Condylomata. 


on  an  ulcerative  and  suppurative  action,  its  size  all  the  while  increas- 
ing, until  a  foul,  painful,  indurated  mass  results,  which  strongly  re- 
sembles malignant  disease. 

Fibromata,  lipomata,  enchondromata,  fetal  inclusions  and  vari- 
ous forms  of  cysts  have  all  been  noted  around  the  rectum,  but  their 
existence  is  so  rare  that  no  detailed  description  is  necessary. 

While  speaking  of  tumors  containing  hair,  etc.,  it  may  be  well  to 
refer  to  an  affection  which  Dr.  Hodges,  of  Boston,  has  described 
under  the  name  of  "  pilo-nidal  sinus  •'  {pilus^  a  hair  ;  nidus,  a  nest), 
and  which  has  for  some  time  been  known  in  French  literature  by  the 


NON-MA LIGFANT    GKOWTIIS   OF   THE   KECTUM   AND   ANUS. 


209 


name  of  the  posterior  umbilicus.  The  affection  is  simply  a  ball  of 
hair  and  dirt  in  a  sinus  between  the  anus  and  the  tip  of  the  coccyx. 
The  sinus  is  a  deep,  symmetrical,  somewhat  conical  dimple  of  con- 
genital origin,  representing  an  imperfect  union  of  the  lateral  halves 
of  the  body,  involving  the  integument  alone,  in  which,  as  life  ad- 
vances, short  hairs  and  other  particles  accumulate.  These,  by  their 
irritation,  cause  a  purulent  discharge  from  the  fistulous  opening  of 


Fig.  127. 
Congenital  Tumor  of  Ano-perineal  Region. 


the  cavity,  and  when  the  case  comes  under  the  observation  of  the 
surgeon  it  is  usually  mistaken  for  fistula  in  ano.  The  hair  being 
removed,  the  sinus  closes  by  granulation. 

This  affection  is  never  found  in  children,  never  in  men  who  do  not 
have  a  large  amount  of  hair  about  the  nates,  and  so  rarely  in  women 
that  the  records  of  the  Massachusetts  General  Hospital  included  but 
a  single  instance,  and  in  this  patient  there  was,  for  a  female,  an  un- 
usual growth  of  hair.  For  the  development  of  the  affection  there 
are  necessary  a  congenital  coccygeal  dimple,  an  abundant  pilous 
growth  (hence  adult  age,  and  almost  of  necessity  the  male  sex),  and 
insufficient  attention  to  cleanliness.  The  affection  is,  therefore,  met 
with  in  persons  of  the  lower  class,  and  in  hospital  rather  than  private 
practice. 

14 


CHAPTER    XIII. 

NON-MALIGNANT   ULCERATION. 

The  many  different  varieties  of  non- malignant  ulcers  wliicli  are 
met  with  at  tlie  anus  and  within  the  rectum  may  best  be  classified, 
from  the  standpoint  of  etiology,  into  the  following  groups: 

1.  Traumatic, 

2.  Catarrhal. 

3.  Tubercular. 

4.  Scrofulous. 

5.  Dysenteric. 

6.  Venereal. 

Traumatic  Ulcers. 

The  most  frequent  traumatism  to  which  the  rectum  is  subject  is, 
perhaps,  that  arising  from  surgical  interference  with  diseases  of  this 
part.  In  certain  subjects  wounds  made  here  by  the  surgeon  may 
refuse  to  heal  under  the  best  of  treatment,  and  when  no  reason 
can  be  found  except  in  the  bad  general  condition  of  the  patient. 

There  is  no  doubt,  however,  that  the  constitution  of  the  patient 
is  sometimes  made  to  bear  the  blame  when  it  more  justly  belongs  to 
the  operator  ;  for  wounds  which  will  heal  promptly  under  the  treat- 
ment of  one  surgeon  may  become  very  intractable  old  ulcers  under 
another.  A  perfectly  healthy  wound  may  be  turned  into  a  sluggish 
sore  by  too  active  attempts  to  induce  it  to  heal.  A  fistula  which  has 
been  cut  and  is  doing  well  may  be  kept  open  indefinitely  by  stuffing 
it  daily  with  lint ;  and  a  fissure  that  would  heal  in  forty-eight  hours 
may  be  changed  into  a  bad  sore  by  an  occasional  application  of  a 
point  of  nitrate  of  silver. 


NON-MALIGNANT   ULCERATION.  211 

Another  not  very  infrequent  cause  of  ulceration  is  the  presence 
and  passage  of  hardened  faeces  containing  perhaps  undigested  sub- 
stances such  as  date-stones,  cherry-pits,  and  seeds  of  fruits.  We 
also  know  that  fecal  impaction  will  cause  sloughing  of  the  rectum, 
and  MacCormac  has  reported  an  interesting  case  of  fatal  perforation 
from  the  pressure  of  scybala. 

Some  of  the  worst  cases  of  traumatic  ulceration  I  have  ever  seen 
have  arisen  from  the  unsurgical  treatment  of  hemorrhoids.  These 
are  always  liable  to  become  at  first  eroded  and  subsequently  ulcer- 
ated from  extrusion  and  the  passage  of  hardened  faeces ;  and  when 
to  these  causes  of  injury  applications  of  nitric  acid  or  injections  of 
carbolic  acid  are  added,  a  severe  ulceration  may  be  excited  which,  as 
in  several  cases  which  have  come  under  my  care,  may  result  in  strict- 
ure of  the  rectum. 

An  injury  to  which  women  alone  are  subject,  and  which  is  believed 
by  many  to  go  far  toward  accounting  for  the  supposed  greater  fre- 
quency of  ulceration  and  stricture  in  them  than  in  men,  is  bruising 
of  the  rectal  wall  in  parturition.  Most  of  the  standard  authors  men- 
tion such  cases. 

CatarrTial  Ulceration. 

A  catarrhal  proctitis,  due  to  any  of  the  causes  mentioned  as 
producing  that  condition,  may  result  in  severe  and  rebellious  ulcera- 
tion. In  some  of  these  cases  I  have  had  great  difficulty  in  deciding 
upon  the  initial  cause  of  the  trouble.  Men,  sometimes  physicians, 
come  to  me,  apparently  otherwise  in  perfect  health  and  with  no 
history  of  traumatism,  with  more  or  less  extensive  erosions  and 
superficial  loss  of  substance  of  the  mucous  membrane,  complaining 
of  the  usual  train  of  symptoms.  In  women  I  have  learned  to  look 
for  a  causative  influence  in  a  malposition  of  the  womb  pressing 
upon  the  rectum  ;  but  the  cause  often  escapes  me  in  both  sexes. 
Two  of  the  worst  cases  I  have  ever  seen,  one  in  a  child  and  the 
other  in  an  adult,  were  due  to  the  irritation  of  undiscovered  polypi 
high  up  in  the  canal,  and  to  injudicious  treatment  for  the  condition 
without  diagnosis. 

For  some  years  back  the  quacks — who  are  ever  active  in  diseases 
of  the  rectum — have  been  devoting  their  special  attention  to  ulceration 


212 


SURGERY    OF   THE   RECTUM    AND   PELVIS. 


of  the  sinuses  of  Morgagni,  which  they  cure  by  slitting  them  up. 
For  my  own  part  I  do  not  often  see  any  of  these  little  pouches  which 
are  sufficiently  developed  to  admit  of  being  slit  open,  to  say  nothing 
of  concealing  an  ulcerated  surface. 

An  eruption  of  herpes  around  the  anus,  similar  to  what  is  seen  on 
the  lips,  may  result,  after  rupture  of  the  primary  vesicles,  in  numer- 


Fig.  l;3S. 
Inflamed  Fissure. 


ous  small  superficial  ulcers  of  a  reddish  color  and  secreting  a  little 
pus.  These  may  coalesce  at  their  edges  and  form  a  serpiginous  sore. 
They  are  apt  to  be  accompanied  by  similar  eruptions  on  other  parts 
of  the  body,  and  must  be  carefully  distinguished  both  from  mucous 
patches  and  soft  chancres.     The  ulcerations  which  result  from  acute 


NOlSr-MALIGlSrAHT   ULCERATION. 


213 


and  chronic  eczema  and  from  pruritus  present  no  special  character- 
istics. They  are  generally  due  to  the  injury  inflicted  by  the  nails  of 
the  sufferer. 

Irritable  Ulcer,  or  .Fissure. 

An  injury  due  to  any  of  the  causes  already  mentioned  may,  in 
certain  persons,  and  when  located  at  the  verge  of  the  anus,  assume 
the  characteristics  of  an  affection  which  has  been  elevated  into  a 
separate  class,  and  is  known  as  fissure,  or  irritable  ulcer.  The 
irritable  ulcer  differs  in  no  respect  from  other  simple  ulcers  in  the 
same  locality,  except  in  the  fact  of  its  irritability.  There  is  nothing 
peculiar  in  the  ulcer  itself.  It  may  be  due  to  a  slight  rent  in  the 
mucous  membrane  from  hard  faeces;  to  a  congenital  narrowness  of 


Fig.  129. 
Microscopic  Appearance  of  Nerve  in  Fissure. 

the  anal  orifice  and  a  naturally  overpowerful  sphincter ;  to  the  irri- 
tation of  a  leucorrhoeal  or  gonorrhoeal  discharge  in  women  ;  to  an 
herpetic  vesicle,  or  to  the  venereal  sore  which  it  so  strongly  resem- 
bles—the soft  chancre.  Any  sore  which  is  fairly  in  the  grasp  of  the 
external  sphincter  is  apt  to  become  an  irritable  or  painful  one,  and 
a  fissure  may  be  painless  at  one  time  and  painful  at  another  in  the 
same  person,  or  painless  in  one  person  and  painful  in  another.  An 
ulcer  associated  with  contracture,  spasm,  and  irritability  of  the 
sphincter  is  what  is  known  as  an  irritable  one,  and  without  this 
condition  it  will  not  properly  come  under  this  classification  ;  but  a 
fissure  may  exist  without  causing  any  of  tliese  symptoms. 

This  contracture  of  the  muscle  may  be  temporary  or  permanent, 
and  is  due  to  the  irritation  of  the  sensitive  nerve-filaments  on  the 


214 


SURGERY  OF  THE  RECTUM  AND  PELVIS, 


surface  of  the  ulcer  by  the  passage  of  faeces,  and  to  the  reflex  action 
excited  thereby;  and  to  many  slighter  causes,  such  as  laughing, 
coughing,  sneezing,  or  position.     It  may  even  come  on  spontaneously 


Pig.  130. 
Tubercular  Ulceration  of  Anus. 


in  persons    of  a  highly  nervous  organization,   or  with   such  slight 
provocation  as  to  appear  to  be  spontaneous. 

These  ulcers  are  generally  situated  at  the  posterior  commissure, 
but  may  be  found  anywhere  on  the  anal  circumference.  They  are 
generally  single,  but  there  may  be  two  or   three.    They  are  more 


NON-MALIGNANT   ULCERATION. 


215 


common  in  women  than  in  men,  because  constipation  is  more  com- 
mon in  the  former  and  because  the  slvin  is  finer.  They  are  confined 
to  no  age  and  are  by  no  means  relatively  rare  in  infants.  They  are 
generally  oval  in  shape,  with  their  long  axis  vertical,  and  involve 
both  skin  and  mucous  membrane,  being  situated  just  at  the  junction 
of  the  two.  In  some  cases  they  have  the  appearance  of  a  simple 
erosion,  in  others  of  an  old  ulcer  with  grayish  base  and  indurated 
edges  which  has  involved  the  whole  thickness  of  the  mucous  mem- 
brane and  extended  fairly  down  to  the  muscle  beneath. 


■'^. 


Fig.  131. 
Fissure  with  Hemorrhoid. 


Ball  lays  great  stress  upon  the  sinuses  of  Valsalva  in  the  causa- 
tion of  fissure.  Many  authors  have  noted  that  at  the  lower  end  of  a 
fissure  there  is  often  an  inflamed  cutaneous  tag,  and  have  stated  that 
for  the  cure  to  be  complete  this  tag  must  be  removed  in  addition  to 
the  usual  operation  for  the  fissure.  These  authors  have  considered 
the  cause  of  the  fissure  to  be  the  usual  tear  or  abrasion  from  strain- 
ing or  from  a  small  foreign  body,  and  the  tag  as  only  an  accidental 
complication.  Ball  believes  that  in  a  large  number  of  cases  the 
etiology  is  as  follows  : 


216  SURGERY    OF   THE   RECTUM    AND    PELVIS, 

During  the  passage  of  a  motion  one  of  tliese  little  valves  is  caught 
by  some  projection  in  the  fecal  mass  and  its  lateral  attachments 
torn  ;  at  each  subsequent  motion  the  little  sore  thus  made  is  re- 
opened and  possibly  extended  ;  the  repeated  interference  vv^ith  the 
attempts  at  healing  ends  in  the  production  of  an  ulcer,  and  the  torn- 
dov^rn  valve  becomes  swollen  and  oedematous,  constituting  the  so- 
called  pile,  or,  as  it  has  sometimes  been  called,  the  "sentinel-pile" 
of  the  fissure.  He  compares  the  condition  to  that  of  a  "hang-nail" 
on  the  finger  (Fig.  131). 

Admitting  this  theor}^,  it  is  easy  to  see  why  the  old  operations  of 
stretching  and  division  of  the  sphincter  are  so  successful  by  putting 
an  end  to  the  slight  laceration  occurring  at  each  movement,  and 
giving  final  rest  to  the  sore.  Ball,  however,  goes  farther,  and  as- 
serts that  merely  snipping  off  the  tag  will  cure  the  fissure. 

The  theory  is  an  attractive  one,  and  there  is  no  doubt  that  the 
"sentinel  pile"  keeps  the  fissure  from  healing;  but  we  have  no 
proof  that  the  fissure  began  in  one  of  the  sinuses,  or  that  the  tag  of 
skin  is  anything  more  than  a  result  of  irritation,  or,  in  fact,  that  it 
may  not  be  the  cause  rather  than  the  result  of  the  fissure. 

From  what  has  been  said  of  the  etiology  of  these  simple  ulcers  it 
is  plain  that  they  must  present  many  variations  in  appearance  ;  yet 
the  diagnosis  of  each  from  the  other,  and  of  the  whole  class  from 
those  which  are  to  follow,  will  not  generally  be  found  difficult  if 
proper  attention  is  given  to  the  history,  the  appearance  of  the  lesion, 
and  its  course.  The  disease  is  generally  of  a  healthy  type,  and  tends 
to  self -limitation  and  spontaneous  cure  rather  than  to  increase.  The 
ulcerative  action  is  generally  superficial,  and  tends  to  extend  on  the 
surface  rather  than  in  depth.  It  is  generally  surrounded  by  the 
signs  of  reparative  action,  and  with  proper  care  will  undergo  cicatri- 
zation. 

When,  however,  these  ulcers  are  improperly  treated,  or  when 
there  exists  such  a  constitutional  state  that  healthy  reparative  action 
cannot  be  excited  by  treatment,  any  of  these  sores  may  assume  a 
condition  of  chronicity  and  sluggishness  with  slow  increase  in  size, 
gradually  encroaching  more  and  more  upon  healthy  tissue  till  a 
large  parrt  of  the  anus  and  lower  rectum  is  involved. 

Such  chronic  ulceration  of  simple  nature,  and  neither  tubercular. 


NON  MALIGNANT   ULCERATION. 


217 


cancerous,  syphilitic,  dysenteric,  nor  lupoid,  will  be  seen  in  all  con- 
ditions of  life  and  in  both  sexes.  It  may  be  very  extensive,  fully  as 
great  as  in  some  of  the  varieties,  yet  to  be  described,  and  may  only 


Fig.  133. 
Tubercular  Ulceration. 


be  diagnosticated  from  them  by  careful  study.     It  may  also  be  prac- 
tically incurable,  except  by  extirpation  or  colostomy. 


Tubercular   Ulcers. 

Tubercular  ulceration  may  occur  as  a  primary  affection,  or  as 
secondary  to  general  tuberculosis  anywhere  along  the  course  of  the 


218 


SURGERY  OF  THE  RECTUM  AND  PELVIS. 


alimentary  canal,  and  it  is  sometimes  seen  involving  the  skin  at  the 
verge  of  the  anus  (Fig,  132). 

The  characters  by  which  such  an  ulcer  may  be  recognized  are  its 
pale  red  surface  covered  with  a  small  quantity  of  serum,  but  devoid 
of  healthy  pus,  and  appearing  as  if  varnished  ;  the  absence  of  all 
surrounding  inflammation  and  of  the  granulations  which  exist  in  a 
healthy  sore  ;  its  tendency  to  spread  in  depth  rather  than  on  the  sur- 
face ;  the  absence  of  any  marked  pain  ;  the  regular  outline  ending 


Fig.  133. 
Tubercular  Ulceration. 


abruptly  in  healthy  skin ;  and,  above  all,  its  chronicity  and  the  utter 
failure  of  all  remedies  to  affect  its  steady  course.  The  diagnosis  may 
be  confirmed  by  the  microscope.  The  tubercles  caseate  and  break 
down,  forming  funnel-shaped  ulcers.  New  tubercles  are  constantly 
formed  in  the  bases  and  edges,  and  these  in  turn  break  down  and  in- 
crease the  size  of  the  ulcer,  while  several  ulcers  may  finally  coalesce. 
The  process  is  sometimes  limited  in  depth  to  the  muscular  layer,  and 
at  others  only  by  the  peritoneum. 


NON-MALIGNANT    ULCERATION.  219 

Such  ulcers  may  be  the  cause  of  stricture  by  the  amount  of  in- 
flammatory deposit  which  surrounds  them.  It  is  exceedingly  diffi- 
cult to  induce  them  to  take  on  a  healthy  reparative  action  ;  and  if 
cicatrization  begins,  the  process  is  generally  incomplete  and  the  cica- 
trix easily  breaks  down. 

A  tubercular  ulcer  starting  in  the  wall  of  the  rectum  may  end  in 
perforation  and  fistula  (fistula  with  large  internal  opening).  Such  an 
ulcer  has  also  been  known  to  cause  sudden  death  from  hemorrhage 
in  a  child,  aged  four  years,  the  subject  of  acute  general  tuberculosis. 

Estheomene. 

Allied  to  the  class  of  ulcers  last  named  are  those  in  which  the 
scrofulous  taint  manifests  itself,  as  it  may  do  either  in  follicular 
ulcers  of  the  rectum  and  large  intestine,  in  lupus  or  esthiomene,  and 
in  rodent  ulcer.  The  last  two  affect  primarily  the  anus  and  peri- 
neum. 

Follicular  ulceration  is  due  to  a  chronic  inflammation  and  fatty 
degeneration  of  the  follicles  of  the  rectum.  These,  which,  when  first 
affected,  appear  as  small  caseous  nodules,  break  and  leave  small, 
deeply  excavated  ulcers,  which,  being  multiple,  may  coalesce  and 
leave  larger  ones  of  the  chronic  variety,  capable  of  subsequent  heal- 
ing with  the  formation  of  cicatricial  tissue. 

They  may  perforate  the  bowel  or  form  fistulse  of  the  blind  internal 
variety  when  low  down,  or  cause  peritonitis  when  higher  up.  They 
may  be  only  one  of  many  manifestations  of  the  scrofulous  tendency 
in  the  same  patient,  and  they  frequently  coexist  with  pulmonary 
disease.  When  low  enough  in  the  intestine  they  may  be  seen 
through  a  speculum,  sometimes  three  or  four  in  the  field  at  once. 

Under  the  title  esthiomene  (lupus  exedens  of  the  ano-vulvar  re- 
gion) a  number  of  phagedenic  ulcerations,  complicated  with  more  or 
less  hypertrophy  of  the  nature  of  elephantiasis,  have  been  described 
by  different  authors. 

Dr.  R.  W.  Taylor,  who  has  made  me  a  firm  convert,  after  j^^ears  of 
clinical  observation,  has  come  to  the  conclusion  that  there  is  no 
such  distinct  disease  as  esthiomene,  and  that  the  term  should  be 
dropped  from  medical  literature.     He  believes,  and  I  agree  with  him, 


220  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

that  any  ulcerative  process  around  the  female  genitals,  syphilitic  or 
otherwise,  if  neglected,  as  it  is  apt  to  be  in  the  lower  walks  of  life, 
may  end  in  the  great  loss  of  tissue  and  hypertrophy  of  tlie  surround- 
ing parts  which  is  generally  described  under  this  name.  His  conclu- 
sions, more  fully  quoted,  are  : 

That  a  large  and  perhaps  the  greater  number  of  chronic,  deform- 
ing vulvar  affections  are  due  to  simple  hyperplasia  of  the  tissues 
induced  by  irritating  causes,  inflammation,  and  traumatism.  That 
chronic  chancroid  is  a  cause  in  a  certain  proportion  of  cases.  That 
many  cases  are  due  to  essential  and  specific  syphilitic  infiltrations. 
That  other  cases  are  caused  by  the  hard  oedema  which  often  compli- 
cates and  surrounds  the  initial  sclerosis  and  perhaps  gummatous  in- 
filtration. That  many  cases  are  due  to  simple  hyperplasia  in  old 
syphilitic  subjects  who  suffer  from  chronic  ulcerations  of  the  vulva 
long  after  all  specific  lesions  have  departed.  That  some  cases  also  in 
old  syphilitics  are  due  to  simply  hyperplasia  without  the  existence 
of  any  concomitant  ulcerative"or  infiltrative  process,  and  seem  to  be 
caused  by  conditions  which  usually,  in  healthy  persons,  only  result 
in  vulvar  inflammation. 

The  ulcer  is  irregular  in  outline,  with  a  granular  base  of  a  violet- 
red  color,  and  there  is  a  slight  sanious  discharge.  The  edges  are  but 
little  elevated  and  are  not  undermined,  and  there  is  more  or  less 
hypertrophy  of  the  surrounding  tissue,  which,  in  some  cases,  is  ex- 
ceedingly well  marked.  The  ulcer  may  cicatrize  in  part,  the  cicatrix 
being  thin  and  white,  at  the  same  time  that  the  ulcerative  process  is 
extending  in  the  opposite  direction.  At  a  little  distance  from  the 
ulcer  there  is  often  a  pathognomonic  appearance  of  slight,  reddish, 
hard  nodules  of  tubercular  lupus,  separated  from  the  primary  sore 
by  healthy  skin.  With  this  amount  of  disease  the  constitutional 
disturbance  is  often  not  sufl5cient  to  confine  the  patient  in  the  house. 

The  diagnosis  is  not  generally  difficult,  though  the  disease  may  be 
confounded  with  cancer,  phagedenic  chancroid,  and  with  elephanti- 
asis with  secondary  ulceration.  It  is  best  distinguished  from  cancer 
by  the  cicatricial  bands  which  it  leaves  behind  in  its  ineffectual  at- 
tempts at  healing,  and  from  chancroid  by  the  surrounding  tubercles, 
which  in  lupus  develop  in  the  thickness  of  the  derma  and  ulcerate 
secondarily  ;  while  the  ulcers  which  sometimes  surround  a  chancroid 


NON-MALIGNANT    ULCERATION. 


221 


are  ulcerous  from  the  first,  being  due  to  secondary  inoculation.  The 
duration  of  the  disease  is  indefinite,  and  it  seldom  leads  to  fatal 
results.  It  is  best  treated  by  destructive  cauterization  and  raclage. 
The  disease  is  well  shown  in  Fig.  134. 


Fig.  134. 

Esthiomene. 


I  have,  by  the  kindness  of  Dr.  Ill,  of  Newark,  N.  J.,  seen  a  very 
unusual  case  of  this  disease,  inasmuch  as  the  patient  was  only  four- 
teen years  old  and  had  been  suffering  since  the  age  of  nine.  The 
usual  manifestations  were  perfect!}^  characteristic,  the  labia  were 
enormously  hypertrophied,  and  the  destruction  of  the  rectum  was  so 


222  SURGERY   OF   THE   RECTUM   AlsD   PELYIS. 

great  as  to  lead  me  to  advise  a  colostomy.  In  this  case  there  was  a 
good  history  of  congenital  syphilis,  and  to  my  surprise  the  patient 
was  very  greatly  relieved  by  anti-syphilitic  treatment. 

Rodent   Ulcer. 

This  is  very  closely  allied  to  epithelioma,  and  may,  in  fact,  be 
considered  one  of  its  varieties  ;  but  it  is  distinguished  from  it  clini- 
cally by  the  fact  that  it  does  not  infiltrate  surrounding  tissue,  does 
not  involve  the  lymphatics,  and  does  not  become  generalized.  It 
is  the  same  disease  met  with  upon  the  face,  and  is  exceedingly  rare 
at  the  anus. 

It  is  found  by  preference  at  the  verge  of  the  anus,  and  extending 
from  this  point  upward  into  the  rectum.  It  is  irregular  in  shape, 
and  its  edges  end  abruptly  in  healthy  tissue.  Its  surface  is  red  and 
dry  ;  it  destroys  superficially,  attacking  mucous  membrane  rather 
than  skin,  and  undergoes  rapid  but  only  partial  cicatrization  under 
proper  local  and  constitutional  treatment.  It  never  entirely  heals, 
and  it  is  not  to  be  included  among  the  causes  of  stricture.  It  is  at 
first  generally  mistaken  for  a  late  syphilitic  manifestation,  but  is  dis- 
tinguishable from  it  by  the  powerlessness  of  all  treatment  to  prevent 
its  steady  progress.  It  is  one  of  the  most  painful  of  aU  the  ulcera- 
tive affections  of  this  part,  and  ends  fatally  unless  some  other  disease 
cuts  short  the  history. 

Dysentery. 

In  dysenteric  ulceration  the  diseased  portion  of  the  lower  bowel 
becomes  infiltrated  with  fibrinous  exudation,  and,  as  a  result  of  the 
compression  which  this  exercises,  is  necrosed  and  sloughs.  When 
the  slough  is  cast  off  there  results  a  loss  of  substance,  and  if  this 
is  superficial  the  membrane  may  regain  its  former  state,  but  if  deep, 
the  usual  callous  cicatrix  is  produced  in  its  place,  and  stricture  is 
the  result. 

The  ulcers  resulting  from  this  process  vary  much  in  size,  location, 
and  appearance.  They  may  be  minute  circles,  but  are  generally 
large,  and,  though  their  favorite  site  is  the  rectum  or  sigmoid  flex- 
ure, they  may  be  found  anywhere  in    the   large   intestine.      They 


NON-MALIGXANT    ULCERATION, 


223 


Fig  135. 
Lupus. 


224  SUEGERY    OF   THE   RECTUM   AND   PELVIS. 

may  extend  so  as  to  coalesce  and  leave  only  islands  of  mucous 
membrane  between  the  extensive  patches.  The  process  usually  in- 
volves only  the  mucous  coat,  but  may  extend  in  breadth  and  result 
in  perforation  and  its  attendant  evils.  The  coats  of  the  bowel  may 
become  sinuous  abscesses,  so  that,  on  dividing  the  prominent  portion 
of  mucous  membrane  between  two  ulcers,  several  drachms  of  pus 
may  escape.  Although  all  the  symptoms  of  dysentery  may  result 
from  ulceration  due  to  other  causes,  there  is  no  doubt  that  in  this 
country  the  disease  is  one  of  the  causes  of  chronic  ulceration  and 
stricture,  and  is  more  common  than  is  generally  supposed. 
The  venereal  ulcers  will  be  treated  of  in  the  next  chapter. 

Symptoms. 

The  symptoms  of  what  is  known  as  the  irritable  ulcer  or  fissure 
are  so  well  marked  as  to  render  its  diagnosis  in  most  cases  easy. 
The  chief  is  the  peculiar  pain,  which  may  be  constant,  but  is 
always  increased  by  defecation.  The  act  of  defecation  itself  may 
not  be  notably  painful,  but  after  the  act,  sometimes  almost  imme- 
diately, sometimes  after  a  short  interval,  the  characteristic  suffering 
begins  and  may  last  in  mild  cases  an  hour  or  two,  or  in  severe  ones 
nearly  all  of  the  twenty-four  hours.  The  pain  is  described  by  the 
sufferers  as  dull,  gnawing,  and  aching,  rather  than  lancinating,  and 
with  it  there  will  often  be  associated  neuralgic  pain  in  the  loins 
and  down  the  thighs. 

As  a  result  of  this  suffering,  at  first  periodic  and  later  constant,  a 
ver}^  miserable  general  condition  is  often  developed.  The  sufferer 
soon  learns  to  dread  the  act  of  defecation  and  to  postpone  it  as 
long  as  possible,  till  a  state  of  chronic  constipation  is  produced 
which  is  overcome  at  long  intervals  by  purgatives  ;  and  in  this  way 
the  whole  digestive  apparatus  is  thrown  out  of  order. 

In  women,  also,  there  is  apt  to  be  reflex  irritation  of  the  bladder, 
with  tenesmus  ;  and  in  men  there  may  be  spasmodic  stricture  of 
the  urethra.  In  women,  also,  it  is  not  uncommon  to  find  uterine 
trouble  combined  with  that  at  the  anus. 

It  is  sometimes  a  matter  of  amazement  to  the  physician  to  see 
how  long  a  woman  will  suffer  from  a  simple  sore  of  this  kind,  and 


NON-MALIGNANT    ULCERATION,  225 

to   what   a   condition   of   invalidism   slie   will   allow   herself    to   be 
Teduced,  before  she  will  seek  for  aid. 

It  will  sometimes  be  found  that  greater  suffering  may  be  caused 
hy  a  simple  erosion  at  the  anus  than  by  more  extensive  and  deeper 
ulceration  ;  and  indeed  the  amount  of  pain  is  not  at  all  indicative 
of  the  depth  or  extent  of  the  sore.  The  element  upon  which  the 
pain  directly  depends  is  probably  the  exposure  of  nerve-filaments. 
Moreover,  the  susceptibility  to  pain  varies  greatly  in  different  peo- 
ple, and  a  woman  of  high  nervous  organization  may  be  reduced  to  a 
■condition  of  chronic  invalidism  by  a  sore  which  would  not  prevent  a 
laboring  man  from  attending  to  his  daily  avocations. 

Ulceration  within  the  rectum  is  also  attended  by  a  certain  train  of 
symptoms  which  render  its  existence  extremely  probable,  and  which 
in  themselves  are  sufficient  to  denote  the  presence  of  an  ulcerative 
process,  though  throwing  no  light  upon  its  nature. 

The  earliest  symptom  is  morning  diarrhoea,  and  that  of  a  peculiar 
character.  The  instant  the  patient  gets  out  of  bed  he  feels  a  most 
urgent  desire  to  go  to  stool.  What  he  passes  is  generally  wind,  and 
some  discharge  resembling  "  coffee-grounds,"  both  in  color  and  con- 
sistence ;  occasionally  the  discharge  is  like  the  "  white  of  an  unboiled 
egg"  or  "  a  jelly-fish,"  more  rarely  there  is  matter.  He,  in  all  proba- 
bility, has  tenesmus  and  does  not  feel  relieved;  there  is  something  of 
n  burning  and  uncomfortable  sensation,  but  not  actual  pain.  Before 
he  is  dressed  very  likely  he  has  again  to  seek  the  closet ;  this  time  he 
passes  fecal  matter,  often  lumpy,  and  occasionally  smeared  with 
blood.  It  also  may  happen  that  after  breakfast,  taking  hot  tea  or 
€offee,  the  bowels  will  again  act  ;  after  this  he  feels  all  right,  and 
goes  about  his  business  for  the  rest  of  the  day,  only  perhaps  being 
occasionally  reminded  by  a  disagreeable  sensation  that  he  has  some- 
thing wrong  with  his  bowel. 

After  this  condition  has  lasted  for  some  months,  more  or  less,  as 
influenced  by  the  seat  of  the  ulceration  and  the  rapidity  of  its  exten- 
sion, the  patient  begins  to  have  more  burning  pain  after  an  evacua- 
tion ;  there  is  also  greater  straining  and  an  increase  in  the  quantity 
of  discharge  from  the  bowel ;  there  is  now  not  So  much  jelly-like 
matter,  but  more  pus — more  of  the  coffee-ground  discharge  and 
Wood. 

15 


226  SUKGERT   OF   THE   RECTUM   AND   PELVIS. 

The  pain  suffered  is  not  very  acute,  but  very  wearying,  described 
as  like  a  dull  toothache,  and  it  is  induced  now  by  much  standing 
about  or  walking.  At  this  stage  of  the  complaint  the  diarrhoea 
comes  on  in  the  evening  as  well  as  the  morning,  and  the  patient's 
health  begins  to  give  way,  only  trifiingly  so  perhaps,  but  he  is 
dyspeptic,  loses  his  appetite,  an(J  has  pain  in  the  rectum  during  the 
night  which  disturbs  his  rest. 

We  need  scarcely  call  attention  to  the  extreme  gravity  of  this  con- 
dition, or  to  the  certainty  with  which,  if  untreated,  and  sometimes, 
indeed,  in  spite  of  the  best  treatment,  it  will  end  either  fatally,  or  in 
stricture  which  will  require  the  gravest  surgical  procedures  for  its 
relief.  The  picture  is  unfortunately  a  familiar  one  to  every  general 
practitioner,  and  a  case  of  severe  or  extensive  ulceration  of  the  rec- 
tum is  perhaps  one  which  calls  for  as  much  skill  in  treatment  as 
anything  in  the  range  of  surgery. 

Diagnosis. 

The  diagnosis  of  the  existence  of  ulceration  is  generally  easy 
with  sufficient  care,  and  may  generally  be  made  from  the  symptoitis 
alone.  A  small  ulcer  within  the  grasp  of  the  external  sphincter 
may  easily  escape  a  cursory  examination  ;  but  no  ulceration,  even 
in  the  upper  part  of  the  rectum,  is  be3^ond  the  reach  of  actual  touch 
or  vision ;  and  none  need,  therefore,  escape  detection  when  the 
examination  is  properly  conducted. 

In  many  cases  the  diagnosis  is  plain,  the  sphincter  will  be  found 
destroyed,  and  the  rectum  and  vagina  will  present  one  common 
cavity  of  foul  appearance,  from  which  issues  a  fetid,  purulent  dis- 
charge. In  other  cases,  by  a  careful  and  gentle  pulling  apart  of 
the  lips  of  the  anus  and  a  gentle  straining  down  on  the  part  of  the 
patient,  a  small  ulcer  within  the  grasp  of  the  sphincter,  or,  at  least, 
its  lower  edge,  will  be  brought  into  view  without  the  use  of  the 
speculum  or  ether.  In  others  a  digital  examination  will  reveal  an 
eroded,  painful  spot  within  the  rectum,  and  when  the  finger  is  with- 
drawn it  will  be  found  stained  with  blood. 

In  all  such  cases  the  diagnosis  is  easy  ;  in  others  there  is  but  one 
way  to  make  a  diagnosis,  and  the  secret  of  success  will  be  found  in 
the  proper  use  of  the  speculum.     This  is  the  way,  I  am  sorry  to 


NON-MALIGNANT   ULCERATION.  227 

say,  wliich  is  least  often  followed  by  the  general  practitioner.  It  is 
much  easier  to  give  a  lady  a  diarrhoea  mixture  and  trust  in  Provi- 
dence for  a  cure  than  to  gain  her  consent  to  be  thoroughly  examined  ; 
and  for  this  reason  many  a  case  of  curable  disease  has  been  allowed 
to  reach  an  incurable  stage  before  its  existence  has  been  certainly 
determined. 

The  existence  of  a  chronic  diarrhoea,  or  of  a  discharge  of  any 
kind  from  the  rectum,  is  always  a  good  and  sufficient  reason  for  a 
thorough  physical  examination ;  and  with  the  instruments  now  at 
our  command,  no  one  need  be  in  doubt  as  to  the  existence  of 
ulceration  in  any  part  of  the  rectum. 

The  existence  of  ulceration  being  decided,  its  nature  remains  to  be 
determined.  We  have  already,  in  speaking  of  the  different  varieties, 
given  some  of  the  chief  points  in  the  differential  diagnosis,  and  to 
these  we  must  again  refer  the  reader.  In  every  case  the  history  must 
be  taken  into  account,  as  well  as  the  appearance  of  the  lesion.  Of  the 
many  varieties  we  have  mentioned,  some  may  almost  certainly  be  ex- 
cluded from  their  great  rarity.  Amongst  these  are  the  true  chancre, 
the  tubercular  deposit,  and  rodent  ulcer.  In  the  majority  of  cases, 
after  excluding  syphilis,  the  ulcer  will  be  of  the  simple  variety  first 
described,  modified  more  or  less  by  the  general  condition  of  the 
patient,  or  it  will  be  malignant. 

Treatment. 

In  speaking  of  the  treatment  of  ulceration  of  the  rectum  and  anus, 
we  will  first  deal  with  the  simplest  form,  the  irritable  ulcer,  and  then 
with  the  more  severe,  postponing  the  question  of  stricture,  which  is 
the  most  frequent  result  of  severe  ulceration,  to  a  separate  chapter. 

The  treatment  of  fissures  at  the  anus  should,  in  the  first  place,  be 
preventive  in  those  persons  in  whom  the  skin  of  the  part  is  sensitive 
and  liable  to  cracks  and  small  sores ;  and  for  such  there  is  nothing 
better  than  the  daily  washing  of  the  part  with  cold  water  and  a  soft 
sponge,  and  the  avoidance  of  anything  which  may  tend  to  irritate  it, 
such  as  the  use  of  printed  or  rough  paper  after  defecation. 

When  fissures  really  exist,  they  may  often  be  cured  by  a  nightly 
application  of  Goulard's  liniment  on  a  pledget  of  lint,  or  by  gently 


228  SURGERY   OF   THE   RECTUM    AND   PELVIS. 

touching  the  surface  with  a  solution  of  nitrate  of  silver  to  coat  the 
sore  (gr.  v.  or  x.-  |  i.). 

I  have  been  surprised,  in  my  own  practice,  at  the  remarkable 
results  which  can  be  obtained  in  the  treatment  of  simple  fissures  by 
local  applications  without  operation.  The  treatment  must  be  carried 
out  with  great  attention  to  detail,  and  by  the  surgeon  himself,  and 
not  the  patient.  It  will  fail  in  many,  but  in  many  others  it  will  suc- 
ceed ;  and  I  have  the  notes  of  many  cures  by  this  means,  some  of 
them  in  a  very  short  time. 

In  children  the  fact  that  fissures  and  erosions  may  be  due  to 
the  scratching  caused  by  the  irritation  of  pin-worms  must  always  be 
borne  in  mind. 

In  fissures  complicated  with  polypi,  the  polypus  must  always  be 
removed  at  the  time  of  the  operation  ;  and  in  women  suft'ering  from 
the  union  of  uterine  and  vesical  trouble  with  painful  ulcer,  the 
uterus  must  be  treated  as  well  as  the  ulcer,  or  the  operation  on  the 
latter  will  be  apt  to  fail. 

In  cases  where  the  treatment  by  local  applications  has  failed  the 
operation  of  drawing  a  sharp  knife  through  the  ulcer  and  muscular 
fibres  directly  beneath  it  is  the  one  to  which  I  give  preference,  pre- 
ferring it  to  stretching,  because  it  can  be  done  in  the  most  satisfactory 
way  with  cocaine,  while  stretching  cannot,  and  because  it  can  be 
done  without  any  fear  of  subsequent  incontinence,  while  stretching 
cannot.  The  cocaine  (five  minims  of  a  four-per-cent.  solution)  should 
be  injected  beneath  the  ulcer.  It  is  customar}^  to  use  a  fenestrated 
speculum  in  such  an  operation,  but  it  may  easily  be  dispensed  with 
when  a  straight,  blunt-pointed  knife  is  used.  The  knife  should  be 
very  sharp,  and  the  operation  must  be  skilfully  done,  but  when 
properly  done  it  is  usually  successful. 

It  is  not  necessary  to  cut  entirely  through  the  sphincter,  and  yet 
those  fibres  of  it  which  form  the  base  of  the  ulcer  should  be  fairly 
divided,  for  it  is  by  putting  an  end  to  the  contractions  of  these  fibres 
that  the  operation  works  its  cure.  The  incision  should  always  be 
extensive  enough  to  produce  a  certain  amount  of  relaxation  of  the 
muscle,  and  should  begin  in  healthy  mucous  membrane  above  the 
ulcer,  and  end  in  the  skin  below. 

The  treatment  of  ulceration  within  the  rectum  is  a  much  more 


NON-MALIGNANT   ULCERATION.  229 

difficult  matter  than  the  treatment  of  tliat  at  the  anus,  and  yet  in 
principle  they  are  the  same.  In  both  we  give  the  ulcer  rest,  and  try 
to  assist  nature  in  her  own  methods  by  avoiding  anything  which 
shall  interfere  with  the  process  of  repair.  The  general  treatment  of 
ulcer  of  the  rectum  may,  therefore,  be  summed  up  in  a  few  words — 
rest,  diet,  and  local  applications.  I  do  not  think  I  exaggerate  when 
I  say  that  without  them  no  treatment  is  likely  to  be  of  much  avail. 

The  rest  in  bed  must  in  some  cases  be  absolute. 

This  point  being  carried  to  the  surgeon's  satisfaction,  milk  diet 
need  not  be  absolute,  but  may  be  varied  with  soups  and  easily 
digested  solids,  as  bread  and  crackers,  care  being  taken  to  secure 
soft  and  unirritating  passages.  With  such  diet  as  this  it  will  some- 
times happen  that  a  movement  of  the  bowels  every  two  or  three 
daj^s  will  be  all  that  nature  requires,  and  as  long  as  such  a  condition 
causes  no  uneasiness  I  am  not  accustomed  to  interfere  with  it  by 
laxatives. 

In  cases  where  it  is  well  borne,  cod-liver  oil  may  be  administered 
both  as  food  and  laxative,  often  with  excellent  effect  upon  the  gen- 
eral condition  and  the  local  trouble.  In  the  way  of  local  applications 
suppositories  may  answer  a  good  purpose  in  disease  low  down. 
The  menstruum  should  be  of  some  substance  which  may  be  easily 
dissolved  at  the  temperature  of  the  body  ;  and  in  the  way  of  drugs  I 
have  had  more  satisfaction  with  bismuth  and  iodoform  than  with 
anything  else.  I  have  also  found  it  well  occasionally  to  mix  about 
the  tenth  of  a  grain  of  morphine  with  the  suppository,  and  admin- 
ister this  at  night  and  morning.  It  certainly  ministers  to  the  local 
rest  of  the  part,  and  it  renders  rest  in  bed  much  more  endurable  in 
persons  of  a  nervous  tendency. 

Certain  good  results  may  be  gained  by  applications  to  the  ulcer- 
ated spot  by  means  of  enemata  or  with  the  brush,  and  Avhen  the 
former  are  used,  in  cases  where  the  disease  is  situated  high  up, 
the  amount  of  fluid  injected  should  be  large.  Tliree  pints  of  water 
may  be  thrown  into  the  upper  part  of  the  rectum,  the  sigmoid  flex- 
ure, and  the  lower  part  of  the  colon,  if  the  proper  means  be  adopted, 
without  causing  any  uneasiness  at  the  time  or  any  subsequent  de- 
sire for  an  evacuation.  Long,  flexible,  soft-rubber  tubes  may  now 
be  obtained  from  any  of  the  surgical  instrument  makers,  which  are 


230  SUEGEEY   OF  THE  EECTUM   AND   PELVIS. 

suitable  for  this  purpose.  The  tube  should  be  small  and  the  open- 
ing in  it  just  large  enough  to  hold  securely  the  smallest  end  piece  of 
an  ordinary  Davidson's  syringe.  The  injection  should  be  given  with 
the  patient  on  the  side,  and  given  slowly.  The  drug  from  which  the 
best  results  may  be  expected,  when  used  in  this  way,  is  the  nitrate  of 
silver,  and  the  solution  should  vary  in  strength  from  twenty  to  forty 
grains  to  three  pints  of  water.  This  plan  of  treatment  has  been  very 
successfully  employed  in  cases  of  dysenteric  ulceration. 

There  is,  however,  no  means  of  treatment  in  cases  of  localized 
ulceration  high  up  the  bowel  at  all,  comparable  in  results  with  the 
application  of  nitrate  of  silver  on  a  uterine  applicator  through  a  long 
speculum.  Every  strength  may  be  used,  from  the  weakest  to  the 
strongest,  and  no  rules  as  to  strength  or  frequency  of  applications 
can  be  laid  down,  for  here  will  appear  the  skill  and  experience  of  the 
surgeon.  I  can  only  say  that  by  the  careful  patient  employment  of 
this  method  I  have  cured  several  cases  of  severe  chronic  ulceration  in 
the  upper  part  of  the  rectum,  beyond  the  field  of  ordinary  vision  by 
the  usual  forms  of  specula,  which  seemed  at  first  sight  to  be  amenable 
only  to  colostomy.  The  use  of  the  instruments  necessary  requires 
special  skill  and  practice,  and  often  some  training  on  the  part  of  the 
patient;  and  the  treatment  is  often  protracted,  but  the  results  are 
exceedingly  satisfactory. 

The  knife  may  serve  a  good  purpose  under  several  circumstances. 
Where  the  sore  is  of  small  dimensions  and  well  limited  in  outline, 
even  though  it  be  above  the  external  sphincter,  it  is  sometimes  of 
advantage  to  make  an  incision  across  the  muscular  fibres  which  form 
its  base,  and  secure  rest  for  it  in  this  way.  The  operation  is  one  of 
delicacy,  but  is  also  one  which  may  assist  greatly  in  the  cure. 

The  application  of  strong  nitric  acid  to  a  circumscribed  ulcer  of 
the  rectum  is  often  attended  by  the  happiest  results. 

In  treating  these  cases  by  local  applications  the  surgeon  must  be 
prepared  to  ring  all  the  changes,  between  a  two-grain  solution  of 
nitrate  of  silver  and  fuming  nitric  acid,  or  pure  carbolic  acid.  They 
are  cases  which  require  the  utmost  care,  both  as  to  the  diagnosis  in 
the  first  place,  and  the  treatment ;  and  many  of  them  will  end  un- 
happily in  spite  of  all  that  can  be  done.  And  yet,  when  they  present 
themselves  in  their  earlier  stages,  before  irreparable  injury  has  been 


NON-MALIGNANT   ULCERATION. 


231 


done,  they  are  capable  of  being  cured  by  the  treatment  which  has 
been  outlined. 

I  now  remember  no  case  of  simple  ulceration,  where  the  disease 
was  seen  at  all  early,  which  I  have  failed  to  cure  by  one  method  or 
another,  but  it  has  often  been  by  several  combined,  and  only  after 


months  of  treatment  and  the  heartiest  co-operation  of  the  patient. 
In  many  cases  the  cure  has  been  easy,  especially  in  those  where  cir- 
cumscribed ulcers  within  the  bowel,  which  have  long  resisted  treat- 
ment, have  been  found  to  depend  upon  blind  internal  fistulee. 


The  practitioner  should  be  very  cautious  in  his  prognosis  as  to 
the  time  required  for  treatment,  remembering  that  it  will  of  necessi- 
ty be  long. 

To  accomplish  anything  with  either  tubercular  or  lupoid  ulcer- 
ation the  treatment  must  be  begun  early.  If  a  tubercular  ulcer  be 
completely  excised  or  destroyed  with  the  cautery  before  general 
symptoms  of  tuberculosis  have  shown  themselves,  there  is  a  chance 
that  it  may  be  cured  ;  and  if  lupoid  ulceration  be  attacked  before  it 
has  done  irreparable  injury,  and  thoroughly  excised,  it  may  also  be 


232  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

induced  to  heal.  By  thorough  excision,  I  mean  cutting  fully  as  wide 
of  the  disease  as  would  be  done  were  it  known  to  be  malignant — at 
least  an  inch  in  every  direction. 


Fig.  138. 
Ointment  Applicator. 


In  the  old  and  advanced  cases,  beyond  the  benefits  of  local  treat- 
ment, there  are  only  too  methods  to  be  followed.  One  is  complete 
resection  of  the  diseased  part,  the  other  is  colostomy. 


CHAPTER  XIY. 

VENEREAL    DISEASES  OF  THE  RECTUM  AND  ANUS. 

The  venereal  diseases  of  the  rectum  constitute  a  study  which  has 
never  yet  been  mastered  by  either  the  syphilographer  or  the  student 
of  diseases  of  the  rectum.  Each  has  contributed  a  certain  amount  of 
information  acquired  by  personal  experience,  but  neither  has  ever 
completely  covered  the  whole  ground. 

The  term  venereal  diseases  will  be  used  here  in  its  broadest 
sense,  as  including  all  those  affections  referable  to,  or  directly 
caused  by,  the  sexual  act ;  and  the  number  of  such  is  very  consider- 
able, for  there  is  scarcely  any  manifestation  of  venereal  disease 
capable  of  affecting  the  soft  tissues  which  has  not  at  some  time 
been  observed  in  the  rectum  or  anus. 

Before  considering  the  various  forms  in  detail,  a  few  words  are 
unavoidable  as  to  the  modes  of  their  acquirement.  Some  of  them 
are  local,  some  are  the  manifestations  of  a  constitutional  poison. 
The  local  ones  may  be  acquired  by  accidental  contact  or  by  the 
practice  of  unnatural  sexual  vice.  However  disgusting  this  last 
phase  of  etiology  may  be,  it  cannot  be  set  aside  as  a  matter  of  an- 
cient history,  nor  utterly  disregarded  in  the  practice  of  medicine  of 
the  present  day. 

There  are  many  points  at  which  this  subject  comes  within  the 
field  of  the  alienist  and  neurologist,  rather  than  that  of  the  surgeon. 

The  French  writers  describe  in  detail  the  changes,  malformations, 
and  diseases  of  the  rectum  and  anus  produced  by  this  practice,  and 
it  is  on  account  of  these  only  that  this  subject  has  been  introduced. 
It  is  a  well-attested  fact  that  all  of  the  supposed  physical  signs 
of   the   vice   may   be    absent   in   those  who   have   practised   it   for 


234  SUEGERY   OF   THE   RECTUM   AND   PELVIS. 

years.  A  case  reported  by  myself  is  one  in  point,  and  Koclier  calls 
especial  attention  to  the  fact  tliat  among  the  Arab  pederasts  all 
of  these  signs  are  generally  absent.  Ligg  describes  a  deaf-mute, 
thirty-five  or  forty  years  old,  the  victim  of  this  habit,  whose  anus 
showed  no  trace  of  traumatism  and  was  well  closed,  being  marked 
only  by  an  absence  of  the  radiating  folds.  The  mucous  membrane 
of  the  rectum  was  also  normal. 

Although  there  is  a  perfectly  normal  type  of  anus,  the  changes 
which  may  be  found  in  it  without  indicating  disease  are  numerous. 
The  tonicity  of  the  sphincter  differs  greatly  in  different  people  in 
health.  In  some  a  Sims  No.  8  speculum  may  be  introduced  without 
pain,  while  others  can  hardly  tolerate  the  index  finger.  In  some 
patients  the  radiating  folds  of  skin  are  very  strongly  marked,  while 
in  others  they  are  entirel}^  absent  ;  and  the  depth  of  the  anal  de- 
pression varies  most  strikingly  in  different  people. 

The  changes  which  unnatural  intercourse  is  supposed  to  produce 
are  relaxation  of  the  sphincter,  disappearance  of  the  radiating  folds, 
and  an  infundibuliform  shape  of  the  anus,  together  with,  in  more 
marked  cases,  fissures,  lacerations,  abrasions,  ecchymoses,  ulcer- 
ation, abscess,  hemorrhoids,  fistulse,  and  incontinence.  There  is  no 
doubt  but  that  all  of  them  may  be  produced  in  this  way,  but  only 
under  extreme  conditions.  It  certainly  would  lead  to  error,  how- 
ever, to  infer  the  existence  of  an  unnatural  practice  from  a  lax 
sphincter  or  an  absence  of  radiating  folds  in  every  case,  or  even  in 
the  majority  of  cases. 

In  studying  these  changes  and  their  value  in  diagnosis,  it  will  be 
safer  to  admit  that,  although  the  prolonged  practice  of  the  vice  may 
certainly  cause  them  to  appear,  they  may  still  all  be  absent  in  old 
cases,  and  their  mere  presence  will  seldom  constitute  proof  of  the 
practice  without  additional  evidence,  usually  only  to  be  obtained 
from  the  confession  of  the  patient. 

The  physical  signs  which  indicate  this  vice  are  of  two  kinds — 
those  due  to  physical  violence  and  those  due  to  direct  contagion  of 
venereal  poison.  The  former  will  vary  according  to  the  age  of  the 
passive  party,  the  tightness  of  the  sphincter,  the  size  of  the  male 
organ,  the  amount  of  violence  used,  etc.,  and  also  according  to  the 
frequency  of  the  act.     In  a  young  child,  and  sometimes  in  an  adult, 


VENEREAL   DISEASES    OF   THE    RECTUM    AND    ANUS.  235 

the  injury  may  Amount  to  actual  laceration,  and  may  be  attended  by 
profuse  hemorrhage  in  consequence  ;  but  it  is  more  apt  to  show 
itself  in  abrasions,  bruising  of  the  parts,  and  ecchymoses.  These 
injuries  may  be  followed  by  abscess,  and  hence  by  resulting  listulse. 

In  less  marked  cases  a  single  act  may  be  followed  by  pain  in  the 
rectum,  increased  by  defecation,  tenderness  to  the  touch,  slight 
erosions,  and  perhaps  by  a  slight  sero-sanguinolent  or  mucous  dis- 
charge. In  cases  of  the  long-continued  practice,  where  marked 
changes  have  been  caused,  the  physical  signs  are  of  a  different  char- 
acter. Tardieu  illustrates  his  work  with  a  plate  of  a  patulous  anus 
in  which  the  sphincter  is  entirely  paralyzed  ;  and  Burgeon  describes 
the  rectum  of  an  idiot,  who  for  a  considerable  time  had  practised  the 
vice,  as  much  dilated  and  infundibuliform  in  shape,  the  mucous 
membrane  being,  blackish,  swollen,  and  ulcerated  in  spots,  and  the 
submucous  and  muscular  layers  hypertrophied  to  four  or  fi^e  lines  in 
thickness.  In  such  cases  there  will  be  incontinence  of  gas  and  faeces, 
fistulse,  and  perhaps  stricture  following  the  ulceration. 

With  regard  to  the  diagnosis  in  these  cases,  it  will  be  seen  that 
none  of  the  signs  enumerated  are  absolutely  diagnostic,  though  they 
may  be  sufficiently  so  to  excite  the  strongest  suspicion. 

The  injuries  caused  by  the  practice  of  rectal  masturbation  are 
often  much  more  severe  than  those  due  to  sodomy  or  pederasty. 
It  is  this  secret  vice  which  lies  at  the  bottom  of  all  the  remarkable 
oases  of  foreign  bodies  found  in  the  rectum,  generally  of  old  men 
who  have  lost  natural  power.  A  bottle  in  the  rectum  explains  itself, 
audit  is  useless  to  call  out  the  story  of  diarrhoea  or  constipation  with 
which  the  sufferer  always  provides  himself. 

One  reason  for  the  fatality  of  these  cases  is  found  in  the  length  of 
time  the  true  condition  will  be  concealed  by  the  patient  before  his 
shame  allows  him  to  seek  medical  relief  ;  and  another  is  that  in  the 
futile  attempts  to  remove  the  body  made  by  the  patient  it  is  generally 
pushed  farther  up,  or,  if  friable,  is  broken. 

Leaving,  with  this  brief  outline,  the  physical  changes  which  may 
result  from  these  practices,  we  come  to  venereal  diseases  of  the  rec- 
tum and  anus  which  may  be  caused  by  them  or  in  other  ways. 

Proctitis  due  to  sodomy  or  pederasty  may  be  either  simple  or 
gonorrhoeal.     The  former  is  due  to  meciianical  violence,  and  its  pres- 


236  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

ence  without  palpable  cause,  and  associated  with  an  eroded  con- 
dition of  the  anus,  is  sufficient  to  excite  a  suspicion  of  the  vice.  The- 
symptoms  are  a  sensation  of  heat  and  weight  in  the  part,  a  frequent 
desire  to  go  to  stool,  more  or  less  pain,  often  extending  to  the  blad- 
der, sacrum,  and  loins,  and  causing  vesical  tenesmus  and  a  discharge 
of  sero-purulent  matter  with  the  passages  and  between  them. 

With  these  local  symptoms  there  may  be  more  or  less  fever  and 
loss  of  appetite,  and  an  examination  will  reveal  local  rise  in  temper- 
ature and  a  congested  state  of  the  mucous  membrane. 

GonorrTicea. 

True  gonorrhoea  of  the  rectum,  arising  either  from  direct  con- 
tagion or  by  inoculation  with  pus  flowing  from  the  vagina  over  the 
anus,  is  very  rare.  Rollett  reports  a  case  due  to  direct  inoculation 
from  the  penis  to  the  rectum  in  a  patient  who  was  in  the  habit  of 
introducing  his  finger  into  the  bowel  to  provoke  a  passage. 

Tardieu  has  never  observed  a  case,  and  Gosselin  saw  only  one  at 
Lourcine  in  three  years. 

In  some  experiments  made  by  Boniere,  he  found  it  very  diflBcult 
to  inoculate  the  rectal  mucous  membrane  with  gonorrhcsal  pu& 
placed  upon  it  through  a  tube,  though  the  anus  was  easily  affected. 
On  the  other  hand,  Requin  believes  it  almost  sure  to  follow  passive- 
pederasty  with  a  person  suffering  from  the  disease. 

Individual  cases  will  occasional!}^  be  seen  reported,  and  most  of 
the  standard  writers  acknowledge  its  existence.  In  my  own  practice 
I  have  never  had  occasion  to  suspect  its  existence  but  once,  and  then 
I  could  not  be  positive  ;  the  patient— a  woman— denying  any  un- 
natural intercourse,  and  there  being  another  explanation  of  the  con- 
dition equally  good. 

The  diagnosis  must  rest  upon  the  confession  of  the  patient,  the- 
existence  of  the  deformities  which  point  to  unnatural  intercourse,  the 
severity  of  the  inflammation,  and  the  microscopic  examination  of 
the  discharge.  In  gonorrhoeal  proctitis  all  the  symptoms  will  be  more 
severe  and  acute  than  in  any  of  the  simple  varieties.  The  pain  is- 
greater,  the  discharge  very  abundant  and  greenish  in  character, 
escaping  with  the  stools  and  also  by  itself  ;  the  finger  introduced  will 


VENEREAL    DISEASES    OF   THE   RECTUM    AND    ANUS.  .  237 

at  once  detect  the  increased  heat  of  the  part,  and  a  speculum  exami- 
nation will  show  intense  redness  and  congestion.  The  mucous  mem- 
brane is  covered  with  thick  discharge,  bleeds  readily  when  touched, 
and  the  follicles  are  enlarged  and  discharge  pus.  Although  a  very 
rsevere  proctitis  may  be  caused  by  other  causes  than  gonorrhoea — 
such,  for  instance,  as  the  prolonged  use  of  drastic  purgatives — the 
history  of  the  development  of  the  disease  will  be  much  more  chronic. 

The  irritating  discharge  from  the  anus  may  cause  erosions  and 
fissures,  or  previously  existing  fissures  may  become  inoculated  with 
gonorrhoeal  pus  and  spread  in  superficial  extent.  The  inflammation 
of  the  mucous  membrane  of  the  rectum  may  be  so  severe  as  to  end 
in  ulceration  and  loss  of  tissue. 

The  treatment  consists  in  rest  in  bed,  hot  sitz-baths,  anodyne  in- 
jections of  w^arm  starch-water  and  opium,  and  perhaps  of  a  solution 
of  nitrate  of  silver  (1  or  2  grs.  to  §  i.).  The  diet  should  be  of  milk 
and  fluids,  and  the  bowels  should  be  kept  gently  acting  with  salines. 
By  this  means  a  cure  may  generally  be  affected  in  a  fortnight  or  three 
weeks. 

Chancroid. 

Chancroids  at  the  anus  may  be  caused  by  direct  contagion  or  by 
auto-inoculation,  and  though  they  may  be  due  to  unnatural  inter- 
course, their  presence  is  no  proof  in  itself  of  the  vice.  They  are 
much  more  common  in  females  than  males,  constituting  one  in  nine 
of  all  cases  of  chancroids  in  the  former,  and  only  one  in  four  hundred 
and  forty -five  in  the  latter.  To  account  for  this  disproportionate  rel- 
ative frequency  it  is  only  necessary  to  remember  the  possibility  of 
-accidental  contact  of  the  male  organ  in  coition,  and  the  facilit}^  of 
auto-inoculation  due  to  the  proximity  of  the  rectum  and  vagina. 

They  may  be  single  or  multiple,  may  be  situated  at  any  point  of 
the  anal  circumference,  and  may  cover  a  large  extent  of  surface. 
They  often  extend  upward  between  the  radiating  folds  of  skin,  and 
thus  greatly  resemble  simple  fissures  ;  or  they  may  spread  backward 
into  the  fold  between  the  nates,  following  in  extent  the  natural 
•course  of  the  discharge  ;  but  they  do  not  tend  to  spread  upward  into 
the  rectum,  or  to  involve  the  surface  of  the  gut  above  the  line  of 
the  sphincter.    When  they  do  so,  which  is  rarely,  they  are  of  limited 


238 


SURGERY    OF    THE    RECTUM    AND    PELVIS. 


-  -:*f^ 


Fia   139. 
Chancroids  of  Anus  and  Vulva. 


VENEREAL   DISEASES   OF   THE   RECTUM   AND   ANUS.  289 

extent  and  well  circumscribed.  Their  existence  in  the  rectum  proper 
has  been  denied  by  good  observers,  erroneously,  I  think,  the  mucous 
membrane  there  being  believed  to  furnish  no  suitable  ground  for 
their  inoculation. 

The  sores  at  the  margin  of  the  anus  have  the  same  general  char- 
acteristics as  when  located  in  other  parts.  The  base  is  soft  and  cov- 
ered with  the  same  grayish  pellicle,  the  edges  are  sharply  punched, 
and  the  secretion  is  profuse.  They  tend  to  spontaneous  cure  with 
cleanliness  or  with  judicious  cauterization,  and  are  not  very  painful 
unless  they  are  within  the  grasp  of  the  sphincter,  w^lien  they  may 
cause  the  usual  pain  of  fissure.  Even  when  they  have  extended  up- 
ward in  this  way  they  still  heal  kindly,  and  almost  spontaneously ; 
and  no  matter  how  completely  they  may  have  involved  the  anus  or 
the  surrounding  skin,  they  seldom,  when  healed,  leave  any  traces  of 
their  former  existence. 

In  certain  rare  cases  they  may  be  accompanied  by  an  undue 
amount  of  ulceration,  known  as  phagedena  ;  and  in  certain  patients 
with  other  rectal  disease,  or  in  whom  the  scrofulous  or  syphilitic  taint 
is  marked,  they  may  assume  a  chronic  type  and  the  healing  be  de- 
layed for  a  long  time  ;  but  even  they  may  generally  be  induced  to 
heal  with  proper  care. 

From  this  general  description  it  is  evident  that  only  under  excep- 
tional circumstances  will  a  chancroid  extend  far  enough  into  the 
rectum,  and  cause  siifficient  destruction,  and  subsequent  cicatrization 
and  fibroid  deposit,  to  result  in  stricture.  That  it  may  do  so  I  am 
forced  to  believe  from  the  testimony  of  others  and  m}^  own  observa- 
tion ;  but  it  is  none  the  less  a  clinical  fact  that  it  seldom  does  so,  as 
all  those  having  large  experience  with  venereal  sores  will  testify. 

Chancroid  as  a  Cause  of  Stricture. 

Gosselin  is  usually  quoted  as  the  authority  for  the  idea  that 
chancroid  of  the  anus  is  the  most  frequent  cause  of  the  severe  ulcer- 
ation, which  results  in  the  so-called  syphilitic  stricture  of  the  rectum. 
It  is  rather  difficult  to  tell  exactly  what  Gosselin  did  mean  in  his 
much-quoted  contribution  to  this  subject,  but  there  seems  very  little 
ground  for  supposing  that  he  intended  to  convey  this  idea.  Although 


240  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

Bassereau  had  made  the  distinction  between  chancre  and  chancroid 
two  years  before,  Gosselin's  "chancre"  still  meant  to  him,  indis- 
criminately, the  hard  chancre,  the  chancroid,  and  the  mucous  patch 
inoculated  by  the  chancroid. 

What  he  asserts  is,  that  these  strictures  are  neither  primary, 
secondary,  nor  tertiary  manifestations  of  syphilis,  as  such  are  gener- 
ally understood,  but  something  developed  in  the  neighborhood  of 
the  primary  sore,  comparable  to  hypertrophy  of  the  labia  or  condy- 
lomata following  the  primary  lesion.  They  are  "due  to  a  special 
modification  of  the  vitality  of  the  tissues  contaminated  by  the  virus 
of  the  chancre,  comparable  to  the  lengthening  and  hypertrophy  of 
the  prepuce  with  contraction  of  its  orifice  which  follows  a  chancre 
on  its  under  surface,  in  which  the  disease  is  evidently  neither  an 
oedema,  nor  a  specific  induration,  nor  a  constitutional  affection,  but 
a  local  lesion,  due  to  the  presence  of  the  chancres,  and  consecutive 
to  the  inflammation  which  they  have  caused." 

Dr.  Mason's  paper  is  very  much  stronger  than  Gosselin's,  in  that 
he  plainly  asserts  the  causation  of  stricture  to  be  the  phagedenic 
chancroid.  He  says  he  has  seen  "  constriction  of  the  rectum  follow, 
and  that  very  shortly  after  the  healing  of  chancroids  has  taken 
place."  Van  Buren  says  :  "I  have  also  seen  chancroids  at  the  anus 
become  phagedenic  and  extend  within  the  rectum,  and  have  verified, 
at  a  later  period,  the  existence  of  stricture  of  the  rectum  from  the 
cicatrization,  as  there  was  every  reason  to  believe,  of  this  same  ulcer- 
ation." 

The  weight  of  evidence  is  thus  seen  to  be  decidedly  in  favor  of  the 
possibility  of  the  causation  of  stricture  by  phagedenic  chancroid,  but 
that  any  large  proportion  of  strictures  are  in  any  way  due  either  to 
chancroid  or  to  syphilis  has  never  been  proved,  while  recent  clinical 
and  microscopic  study  is  all  against  this  time-honored  theory. 

The  diagnosis  of  the  chancroid  in  this  location  will  be  easy  by 
auto-inoculation,  if  the  probability  of  its  occurrence  is  only  borne  in 
mind,  and  the  treatment  has  been  sufficiently  hinted  at.  Cleanliness, 
local  application  of  astringents,  and  attention  to  the  general  health 
are  all  that  is  necessary  when  the  sore  does  not  extend  beyond  the 
radiating  folds. 

There  are  two  forms  of  phagedena  which  may  complicate  a  chan- 


VK.VEKEAL    DISEASES    OF   THE    KECTUM   AND    ANUS.  241 

croid  at  the  anus — tlie  acute  and  chronic.  The  former  is  rare,  and 
strongly  resembles  phlegmonous  erj^sipelas  following  a  wound,  in 
that  it  may  involve  the  tissues  to  a  great  extent,  cause  deep  collec- 
tions of  pus  and  destruction  of  tissue,  and  end  fatally.  The  chronic 
is  the  one  generally  seen,  and  this  may  go  on  for  a  long  time,  healing 
in  one  spot  while  advancing  in  another.  It  is  worthy  of  note  that 
even  after  months  of  this  process  the  sore  still  remains  auto-inoculable. 
There  are  other  complications  of  the  chancroid  which  may  render 
the  diagnosis  difficult.  The  sore  may  itself  be  inoculated  with  syphi- 
litic virus  and  assume  some  of  the  characters  of  the  hard  chancre, 
especiall}^  the  induration.  In  such  a  case  the  diagnosis  must  rest  in  a 
great  measure  upon  the  combination  of  symptoms.  The  sore  will  pre- 
sent the  appearance  of  the  chancre,  but  the  discharge  will  be  more 
abundant  than  a  chancre  generally  produces,  and  the  pus  will  still  be 
auto-inoculable.  In  addition,  the  glands  in  the  groins  will  show  the 
characteristic  syphilitic  induration. 

Treatment  of  Chancroids. 

In  the  treatment  of  chancroids  of  the  anus  many  points  of  diffi- 
culty may  arise.  The  sore,  from  its  position  within  the  grasp  of  the 
sphincter,  may  be  so  painful  that  nothing  can  be  done  to  it  except  by 
the  surgeon  himself,  and  only  then  by  the  exercise  of  the  greatest 
care  and  gentleness  of  manipulation  ;  and  although  this  pain  may 
be  at  once  I'elieved,  either  by  incising  the  ulcer  or  dilating  the  anus, 
both  of  these  procedures  involve  a  great  risk  to  the  patient  of  auto- 
inoculation.  The  bowels  should,  therefore,  be  kept  gently  open  by 
the  daily  administration  of  a  laxative  which  will  cause  soft  but  not 
watery  passages.  The  ulcer  must  be  touched  two  or  three  times 
daily  with  a  weak  solution  of  nitrate  of  silver  (grs.  v.-  §  i.)  on  a  camel's- 
liair  brush,  and  subsequently  covered  with  a  small  pledget  of  soft 
lint  gently  laid  into  the  fissure  and  pressed  down  with  a  probe. 
With  a  light  touch  this  may  be  done  without  causing  pain. 

Should  the  ulcer  have  extended  upward  to  the  upper  edge  of  the 
sphincter,  there  will  be  such  contraction  of  the  muscle  that  this  plan 
of  treatment  is  impracticable,  because  all  parts  of  the  sore  cannot  be 
reached  by  the  brush.     In  such  a  case  ether  must  be  resorted  to,  a 

16 


242  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

specalum  introduced  until  every  part  of  tlie  ulcer  is  exposed,  and 
the  surface  thorougiily  cauterized  with  fuming  nitric  acid.  The  acid 
must  be  carried  under  the  edges  of  the  ulcer,  and  every  point  must 
be  thoroughly  destroyed,  for  the  operation  will  be  positively  injuri- 
ous unless  thoroughly  done. 

Should  the  ulcer  have  reached  such  an  extent  of  rectal  surface  as 
to  render  it  doubtful  whether  by  anj^  means  of  exposure  every  point 
of  it  can  be  fully  seen,  it  is  better  not  to  try  cauterization,  but  to  be 
satisfied  with  astringent  injections  frequently  repeated.  These  must 
also  be  made  either  by  the  surgeon  or  a  thoroughly  well-trained  and 
skilful  assistant,  for  no  fresh  wounds  must  be  made  by  the  point  of 
the  syringe,  and  no  pain  need  be  caused  by  its  passage.  A  small 
glass  point  or  a  small  soft-rubber  catheter  must  be  gently  introduced 
on  the  side  opposite  the  ulcer,  and  about  four  ounces  of  water 
thrown  up  and  passed  out  to  clean  the  surface  of  the  sore.  This 
should  be  followed  by  about  two  ounces  of  a  solution  of  nitrate  of 
silver  (grs.  ij.-|i.),  and  this  application  should  be  repeated  at  least 
three  times  in  the  twenty-four  hours. 

Phagedena  in  the  chronic  form  must  be  treated  by  destructive 
cauterization,  preferably  with  the  Paquelin  cautery,  and  every  part 
of  the  ulcer  must  be  completely  destroyed.  Subsequently  anodynes 
may  be  freely  used  till  the  eschar  separates  and  a  healthy  granulat- 
ing surface  remains.  In  the  acute  form  of  phagedena  free  incisions 
may  be  necessary  in  the  fossse  and  over  the  buttocks  to  let  out  pus 
and  relieve  tension,  as  well  as  the  destructive,  cauterization  of  the 
sore. 

Chancre. 

True  chancre  at  the  anus  is  not  very  uncommon,  though  it  often 
passes  unnoticed  from  the  slight  annoyance  caused  by  it.  In  men 
its  presence  is  very  positive  proof  of  pederasty,  there  being  no 
chance  of  accidental  inoculation  as  in  women.  When,  therefore, 
Pean  and  Malassez  give  the  proportion  of  one  chancre  at  the  anus  to 
every  one  hundred  and  seventy-seven  in  other  parts  of  the  body  in 
men,  they  also  give  some  idea  of  the  amount  of  unnatural  vice  exist- 
ing in  Paris.  The  same  observers  give  the  proportion  as  one  in  thir- 
teen in  women.     These   sores  are   most   likely  to  be   mistaken   for 


VENEREAL   DISEASES   OF   THE   RECTU:M   AND   ANUS.  243 

simple  abrasions,  or,  when  between  the  radiating  folds,  for  simple 
fissures.  When  typical  in  development  they  have  the  hard,  raised 
outline  and  indurated  base,  but  they  are  often  mere  erosions  and 
strongly  resemble  the  mucous  patch.  There  is  very  little  discharge, 
and  what  there  is  is  not  auto  inoculable.  They  tend  to  spontaneous 
healing,  but  they  may  develop  into  mucous  patches.  Glandular 
enlargements  in  the  groins  should  always  be  searched  for,  and  in 
doubtful  cases  constitutional  treatment  may  be  delayed  until  the  ap- 
pearance of  secondary  symptoms. 

True  chancre  within  the  rectum  has  seldom  been  observed,  though 
how  common  it  may  be  as  a  result  of  unnatural  intercourse  will 
never  be  known,  so  little  local  and  constitutional  disturbance  does  it 
cause.  Ricord,  Fournier,  and  Yidal  de  Cassis  each  i-eport  a  single 
case,  and  these  are  about  the  only  ones  recorded.  In  that  of  the 
last-named  the  induration  is  said  to  have  been  so  great  as  to  cause 
stricture — a  statement  which  must  of  necessity  throw  doubt  upon 
the  diagnosis.  The  difficulties  attending  the  diagnosis  of  such  a  sore 
are  manifest.  Its  mere  appearance  would  scarce  be  conclusive,  and 
the  absence  of  any  other  sore  which  might  be  followed  by  general 
symptoms  would  need  to  be  fully  established,  which  in  a  woman  is  a 
very  delicate  thing  to  do. 

Dr.  F.  Hartley  has  reported  a  typical  and  well-studied  case  of 
chancre  within  the  rectum.  Male,  aged  thirty-two,  organist ;  admit- 
ted to  Roosevelt  Hospital  September,  1890.  No  tubercular,  renal, 
or  cardiac  history  in  family  or  self.  Denies  all  previous  venereal 
history.     Had  dysentery  some  years  ago. 

About  three  weeks  before  admission  patient  noticed  severe  pain 
on  defecation,  and  a  small  lump  just  within  the  anus  ;  pain  now 
continues ;  tenesmus  after  each  passage.  Occasionally  blood  at 
stools.     Has  suffered  from  constipation  a  long  time. 

An  ulcer  is  found  just  one  inch  from  the  anal  margin  ;  it  is  about 
the  size  of  a  quarter  of  a  dollar;  the  base  is  indurated  and  the  ulcer- 
ation very  superficial ;  sacral  glands  enlarged ;  no  evidence  of  any 
other  lesion. 

Under  ether  the  ulcer  was  cauterized  with  Paquelin  cautery  and 
dusted  with  iodoform,  and  the  patient  placed  in  the  wards  to  await 
evidences  of  constitutional  syphilis.     Ten  days  later  there  was  rose- 


244  SURGERY   OF  THE   RECTUM   AND   PELVIS. 

ola  over  chest  and  abdomen,  and  twenty  days  later  still  a  papular 
sypliilide  of  face,  forearm,  trunk,  and  portions  of  the  extremities. 
The  rectum  was  by  this  time  healed,  and  the  patient  w^as  put  upon 
antisyphilitic  treatment. 

He  subsequently  confessed  that  three  weeks  before  admission  he 
was  the  victim  of  another  man. 

Secondary  Syphilis. 

The  secondary  manifestations  of  syphilis  around  the  anal  region 
are  some  of  the  syphilodermata,  mucous  patches,  and  condylomata. 

Mucous  patches  are  very  frequent  and  assume  two  distinct  forms, 
the  ulcerative  and  the  vegetating.  The  latter  begins  as  a  slightly 
raised  red  papule,  which  may,  after  a  time,  become  a  mere  erosion 
or  a  distinct  ulcer.  They  are  generally  multiple,  and  may  be  seated 
around  the  anus,  within  the  radiating  folds,  looking  exactly  like 
simple  fissures,  or  anywhere  in  the  ano-perineal  region. 

They  are  easily  confounded  with  either  chancres,  chancroids,  or 
fissures,  and  the  differential  diagnosis  may  be  extremely  difficult, 
and  only  to  be  made  by  the  history  and  the  results  of  treatment. 
The  points  to  be  sought  for  are  the  raised  edges  and  the  grayish 
pellicle,  which  are  not  found  in  simple  fissures. 

Condylomata. 

The  surface  of  a  mucous  patch  sometimes  becomes  elevated  by 
an  upward  growth  of  branching  papillae,  with  production  of  connec- 
tive tissue  and  dilatation  of  the  blood-vessels.  When  this  develop- 
ment has  reached  a  considerable  extent,  a  cauliflower  appearance  is 
the  result,  and  what  was  at  first  a  simple  mucous  patch  may  become 
a  large,  warty  vegetation  surrounded  by  other  similar  growths 
which  have  sprung  up  around  the  original  lesion,  and  which  are 
due  to  direct  auto-inoculation. 

These  are  known  as  vegetating  mucous  patches,  vegetating  con- 
dylomata, condylomata  lata,  syphilitic  condylomata,  etc. ;  and  it  is 
to  them,  to  the  exclusion  of  other  warty  growths  of  nonsyphilitic 
origin,  and  of  tags  of  hypertrophied  skin,  that  the  name  of  condylo- 
mata should  be  limited. 


VENEREAL   DISEASES   OF   THE   IIECTUM   AND   ANUS. 


245 


The  vegetating  mucous  patch  is  particularly  common  around  the 
anus,  and  sometimes  grows  to  a  large  size,  nearly  filling  the  inter- 
gluteal  cleft.     The  secretion  is  in  the  highest  degree  infectious,  and 


,,ifl\^irfftflli 


!>--- 


d-~ 


Fig.  140. 
Syphilitic  Ulceration  of  Colon. 

a.  Swollen  follicles  with  gummy  infiltration. 
6.  Commencing  ulceration  of  follicle. 

c.  Ulcer  showing  subcutaneous  connective  tissue. 

d.  Ulcer  exposing  muscular  layer. 


is  also  auto-inoculable.  The  spreading  of  the  growth,  where  it 
comes  in  contact  with  a  moist  surface,  may  be  accounted  for  by 
direct  auto-inoculation,  and  also  by  the  general  syphilitic  infection, 
which,  at  this  stage,  is  particularly  apt  to  manifest  itself  in  mucous 
patches  at  any  point  in  the  body  which  is  both  moist  and  irritated. 


246  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

These  growths  are  therefore  found  most  developed  in  fat  people  of 
uncleanly  habits  in  either  sex. 

The  treatment  is  both  general  and  local.  Mercury  is  given  for 
the  syphilitic  infection,  of  which  these  growths  are  the  proof,  and 
the  sores  themselves  are  treated  by  the  application  of  calomel  or 
iodoform  in  powder,  by  astringent  washes,  and  the  interposition  of 
pieces  of  lint  between  the  warts  and  healthy  parts  to  avoid  further 
local  contamination. 

Should  the  growths  not  yield  rapidly  to  this  treatment,  they 
may  be  freely  destroyed  by  acid. 

One  point  of  great  interest  in  connection  with  these  syphilitic 
condylomata  is  that  they  very  closely  resemble  (so  closely  that  to 
distinguish  between  them  by  gross  appearances  may  be  impossible) 
another  variety  of  warty  growth  which  is  often  seen  in  the  same 
place,  but  has  nothing  to  do  with  s^^philis,  and  may  be  entirely  in- 
dependent of  any  venereal  disease  whatever. 


The  Mucous  Patch. 

Do  mucous  patches  ever  occur  within  the  rectal  pouch  ?  From 
analogy  with  the  fauces  alone  it  would  probably  be  safe  to  answer  in 
the  affirmative  ;  but  this  is  one  of  the  points  on  which  clinical  evi- 
dence is  especially  to  be  desired.  Molliere  is  the  only  observer  with 
whom  I  am  acquainted  who  has  reported  such  a  case.  He  describes 
a  white,  pearly,  rounded  plaque,  in  a  subject  evidently  syphilitic, 
about  one  centimetre  in  diameter  and  five  centimetres  above  the  anus. 

It  is  known  that  any  ulcerative  lesion,  often  of  a  very  trifling 
nature  originally,  may  in  the  rectum,  under  the  influence  of  the  irri- 
tation of  the  fseces,  assume  considerable  proportions  ;  and  it  has 
been  assumed  rather  than  proved  that  a  mucous  patch  in  the  rectal 
pouch  may  in  this  way  become  the  cause  of  destructive  ulceration, 
subsequent  cicatrization,  and  hence  of  stricture,  so-called  syphilitic. 
There  is  no  clinical  proof  of  this,  as  far  as  my  reading  goes,  nor  are 
we  forced  to  accept  any  such  theory,  however  probable  and  plausible 
it  may  be,  to  account  for  the  strictures  and  ulcerations  of  the  rectum 
which  arise  daring  the  secondary  stage  of  syphilis. 


VENEREAL   DISEASES    OF   THE    RECTUM    AND    AISTUS.  '     247 

At  this  point  we  have  to  leave  this  question,  with  the  others,  for 
future  accurate  clinical  observation,  only  observing  that,  as  Molliere 
points  out,  at  no  other  part  of  the  body  are  mucous  patches  followed 
by  retractile  cicatrices. 

Secondary  Syphilitic  Ulceration. 

Of  the  existence  of  syphilitic  ulceration  of  the  rectal  pouch  occur- 
ring in  the  late  secondary  or  early  tertiary  stage  of  the  disease, 
there  can  be  no  more  doubt  than  of  the  existence  of  the  same  con- 
dition in  the  fauces  and  trachea,  where  it  is  more  easily  discover- 
able and  hence  has  been  more  often  described.  The  ulcer  is  due  to 
the  deposit  of  syphilitic  tubercle  in  tlie  mucous  membrane,  which 
rapidly  comes  to  the  surface,  disintegrates,  and  leaves  a  small,  well- 
marked  loss  of  substance,  with  clearly  cut  edges  and  yellowish, 
purulent  base. 

When  these  ulcers  coalesce  there  is  sometimes  great  destruction 
•of  tissue,  and  large  cicatrices  follow  their  healing.  Their  favorite 
seat  is  the  lower  part  of  the  rectum,  and  when  found  in  great  num- 
bers they  will  gradually  decrease  in  frequency  as  the  bowel  is  fol- 
lowed upward.     (Fig.  139.) 

This  form  of  ulceration  has  been  long  recognized  and  has  been 
thoroughly  described,  but  better  studied  on  the  post-mortem  table 
than  in  the  consulting-room.  It  is,  to  my  mind,  entirely  independ- 
ent of  any  venereal  lesion  at  the  anus  which  may  extend  into  the 
rectal  pouch.  It  is  syphilitic,  and  it  belongs  to  a  late  stage  of  syph- 
ilis. It  is,  moreover,  syphilitic  ulceration  of  the  rectum,  and  not  of 
the  anus,  and  it  begins  an  inch  or  more  above  the  external  sphincter. 

While  thus  freely  admitting  what  others  have  described  and  what 
I  have  myself  seen  in  a  few  cases — the  existence  of  syphilitic  ulcer- 
ation of  the  rectum,  I  believe  it  to  be  a  rare  condition,  one  curable 
by  constitutional  treatment,  and  one  which  in  no  way  accounts  for 
the  condition  of  hypertrophy  of  the  surrounding  tissues  and  steno- 
sis so  commonly  described  as  "syphilitic  stricture  of  the  rectum." 
Both  chancroids  and  secondary  syphilitic  ulcers  may  cause  a  strict- 
ure, but  only  in  very  rare  cases,  and  the  contraction  is  then  purely 
•cicatricial  and  not  hypertrophic.     (See  Proctitis.) 


248  StFRGEKY   OF   THE   RECTUM   AND   PELVIS. 


Gummata. 

The  other  tertiary  manifestations  of  rectal  syphilis  are  neoplastic 
in  character.  Circumscribed  gummy  deposits  of  greater  or  less  ex- 
tent have  been  quite  frequently  noted,  and  are  scarcely  as  rare  as 
would  seem  to  be  indicated  by  the  statement  of  Fournier  that  he  had 
never  seen  a  case.     Other  observers  have  reported  isolated  cases. 

The  deposit  may  occupy  any  part  of  the  circumference  of  the 
bowel,  and  in  one  of  Taylor's  cases  was  located  in  the  recto-vag- 
inal septum,  and  had  ulcerated  through,  causing  a  fistula.  The 
diagnosis  of  such  a  tumor,  with  its  attendant  ulceration,  offers  but 
few  difficulties,  and  the  treatment  is  both  local  and  constitutional. 


Ano-Mectal  Syphiloma. 

Instead  of  being  circumscribed,  this  gummy  deposit  has  been  de- 
scribed as  involving  the  whole  circumference  of  the  bowel,  and  ex- 
tending from  the  sphincter  as  far  as  the  upper  limit  of  the  rectal 
pouch.  This  is  what  Fournier  has  named  ano-rectal  syphiloma,  and 
what  he  believes  to  be  the  explanation  of  the  cases  of  so-called  syphilitic 
stricture.  For,  although  he  recognizes  that  stricture  may  result  from 
late  secondary  ulceration  in  the  manner  we  have  described,  he  believes 
that  stricture  from  this  cause  is  infrequent  as  compared  with  that  pro- 
duced by  this  diffuse  deposit  in  the  rectal  wall. 

As  described  by  him,  the  disease  commences  as  an  infiltration  of 
the  rectal  wall  by  this  neoplasm.  The  deposit  is  entirely  submucous, 
and  occurs  by  preference  in  the  rectal  pouch,  and  always  encircles 
the  whole  calibre.  It  may  also  involve  the  anus,  and  may  take  the 
form  of  anal  tags  and  tumors  described  when  speaking  of  condylomata. 

At  first  it  merely  causes  thickening  and  stiffening  of  the  gut,  so 
that  it  loses  its  dilatability,  but  there  is  no  contraction  and  no  ulcer- 
ation until  later.  As  the  deposit  increases  in  amount,  the  mucous 
membrane  over  it  loses  its  vitality  and  becomes  ulcerated,  and  the 
deposit  itself  finally  degenerates  into  fibrous  tissue,  retracts,  and 
causes  stricture. 

This  description  of  the  gross  appearances  and  general  character- 


VENEREAL   DISEASES    OF   THE    RECTUM    AND    ANUS.  249 

i&tics  of  the  so-called  syphilitic  stricture  will  be  recognized  by  all. 
Fournier  was  not  describing  any  new  affection,  but  simply,  under 
a  new  name  "  ano-rectal  syphiloma,"  endeavoring  to  give  a  com- 
plete history  of  the  origin  and  development  of  the  ordinary  stricture 
as  seen  by  every  practitioner,  and  commonly  attributed  to  syphilis  for 
lack  of  positive  knowledge  as  to  its  etiology,  and  his  description  in 
many  points  corresponds  with  clinical  experience. 

It  must  be  admitted  that  in  most  of  these  cases  of  stricture  there 
is  more  inliltration  of  the  rectal  wall,  more  occlusion  of  the  canal  by 
hard  masses  of  tissue,  more  extensive  disease,  in  other  words,  than 
can  easily  be  accounted  for  by  mere  cicatricial  contraction,  but  such 
a  process  as  Fournier  describes  is  unknown  in  any  other  part  of  the 
body,  and  equally  unknown  as  any  process  characteristic  of  syphilis. 
Nor  is  it  in  any  way  amenable  to  anti-syphilitic  treatment,  the 
condition  being  simply  a  chronic  hypertrophic  proctitis,  independent 
of  syphilis. 


CHAPTER  XV. 

NON-MALIGNANT    STRICTURE    OF    THE    RECTUM. 

For  convenience  of  reference  the  following  table  of  the  different 
varieties  of  stricture  of  the  rectum  has  been  prepared  : 


^  .,   ,      f    1.  Complete. 

Congenital.    |    ^    p^^.^f^i^ 


Acquired. 


1.  Pressure  from  without. 

2.  Spasm. 

3.  Dysenteric. 

4.  Inflammatory. 

5.  Traumatic. 

6.  Tubercular. 

7.  Venereal.   From  Chancroid.  From    Secondary  and 

Tertiary  Ulceration. 


The  congenital  narrowing  of  the  rectum,  both  complete  and  par- 
tial, which  is  sometimes  seen,  has  been  already  described  in  speaking 
of  the  malformations  of  this  part. 

Stricture  Due  to  Pressure  from  Without. 

A  tumor  of  any  kind  in  the  pelvis  will  not  infrequently  press  upon 
the  rectum  so  as  to  obstruct  its  calibre.  An  abscess  in  the  pelvis 
in  men  may  be  accompanied  by  an  amount  of  inflammatory  deposit 
around  the  rectum  sufficient  to  obstruct  it ;  and  a  pelvic  inflammation 
in  women  may  be  accompanied  by  an  exudation  which,  either  by  its 
size  or  in  the  form  of  bands  across  the  bowel,  shall  partially  close  it. 
(See  Fig.  45.) 

I   once   did  colostomy   for  stricture   of    the    rectum    with    nu- 


NON-MALIGNANT   STRICTUEE    OF   THE   RECTUM.  251 

merous  and  large  fecal  and  urinary  fistulse,  due  to  old  hip-joint  dis- 
ease and  abscesses.  Both  rectum  and  urethra  were  tightly  closed 
and  almost  entirely  destroyed  by  chronic  inflammation  and  abscesses 
in  the  surrounding  tissues. 

Spasmodic  Stricture. 

Much  has  been  written  in  times  past  upon  the  question  of  spas, 
modic  stricture  of  the  rectum,  but  for  a  long  time  the  condition  was 
looked  upon  by  the  best  authorities  with  great  doubt,  if  not  with  ab- 
solute unbelief.  Spasmodic  contraction  or  stricture  of  the  external 
sphincter  is  not  an  unusual  condition,  but  spasmodic  stricture  of 
the  canal  above  this  point  has  always  been  a  matter  of  belief  and  as- 
sertion rather  than  of  demonstration. 

I  have  already  referred  to  the  difficulty  which  often  exists  in 
passing  a  rectal  bougie,  from  the  natural  confirmation  of  the  parts. 
It  is  upon  this  difficulty  that  nearly  all  the  arguments  for,  and  the 
supposed  cases  of,  spasmodic  stricture  rest.  When  the  bougie  can- 
not be  passed  a  spasmodic  or  organic  stricture  is  supposed  to  be  the 
cause.  When,  after  numerous  trials,  by  a  lucky  manipulation  an 
entrance  is  effected,  the  spasm  has  been  overcome.  To  this  may 
be  reduced  nearly  all  the  reported  cases  of  this  affection  which  from 
time  to  time  have  appeared  in  the  writings  of  those  who  have  devoted 
attention  to  the  subject. 

Molliere,  with  his  usual  happy  style,  has  gone  very  nearly  to  the 
bottom  of  this  question. 

He  sa3^s  that  at  a  not  very  remote  period  there  flourished  by  the 
side  of  Ashton,  Curling,  and  the  surgeons  of  St.  Mark's  Hospital, 
certain  specialists  as  expert  in  finding  strictures  in  the  rectum  as 
our  laryngologists  in  discovering  polypi  in  the  larynx.  These 
estimable  practitioners  gave  themselves  up  to  the  daily  exercise  of 
dilatation  by  bougies,  and  to  facilitate  the  practice  one  of  them  had 
invented  a  pair  of  pants  of  a  special  pattern,  dressed  in  which  novel 
livery  his  patients  came  daily  to  have  a  sound  introduced  into  the 
anus. 

This  whole  question  of  spasmodic  stricture  has  been  very  ably 
discussed  by  Van  Buren,  and  if  the  reader  wishes  to  follow  it  further 


252  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

he  can  scarcely  do  better  than  to  consult  that  author.  Uncompli- 
cated spasmodic  stricture  of  the  rectum  is  a  thing  whose  existence 
was  for  a  long  time  not  admitted  by  the  best  authorities,  and  which 
will  seldom  be  found  by  a  skilful  examiner.  It  is,  perhaps,  too 
much  to  say  that  it  never  exists  ;  but  a  well-marked  case  of  it  with- 
in easy  reach  of  the  finger,  which  can  be  plainly  detected  by  an  or- 
dinary examination,  and  which  disappears  under  chloroform,  will 
seldom  be  seen. 

Nevertheless,  as  my  own  chances  of  observation  have  increased  I 
have  come  to  have  greater  faith  in  the  occasional  existence  of  this 
condition  as  a  surgical  curiosity,  agreeing  in  this  with  Ball,  Cripps, 
and  other  later  writers.  The  following  is  a  case  in  point.  The 
patient  was  a  very  nervous  physician,  worn  out  by  suffering  from 
rectal  disease.  His  one  chief  symptom  was  pain  in  the  I'ectum, 
caused  by  defecation  and  increased  by  the  sitting  posture,  lasting 
often  for  many  hours  after  a  movement  of  the  bowels.  On  touching 
the  skin  near  the  anus,  in  an  attempt  to  draw  the  parts  open  for  in- 
spection, I  found  the  pain  was  so  intense  as  to  cause  him  to  cry  out 
at  the  least  touch.  With  much  gentleness  the  finger  was  passed 
through  the  external  sphincter,  and  met  by  a  stricture  at  about  an 
inch  above^n  other  words,  at  the  level  of  the  internal  sphincter  or 
slightly  above.  A  few  days  later  he  was  etherized,  and  before  giv- 
ing the  anaesthetic  this  condition  was  again  verified  both  by  myself 
and  my  associate.  The  ether  was  then  given,  and  not  till  profound 
narcosis  had  been  reached  did  the  constriction  disappear.  The 
patient  was  found  to  be  suffering  from  hemorrhoids  and  an  ulcer  the 
size  of  a  silver  half-dollar,  but  quite  superficial,  over  the  internal 
sphincter.  The  cure  of  these  was  followed  by  the  relief  of  all  symp- 
toms. 

This  was  certainly  a  case  of  purely  spasmodic  stricture,  but  too 
near  the  anus  to  prove  the  point  under  discussion — spasmodic  strict- 
ure of  the  rectum  proper  ;  though  if  we  may  have  spasmodic  strict- 
ure of  the  unstriped  muscular  fibres  of  the  internal  sphincter,  why 
may  we  not  have  the  same  an  inch  higher  up  ? 

Dysenteric. — Dysenteric  ulceration  with  stricture  has  been  al- 
ready described  under  non-malignant  ulceration.  Stricture  due  to  this 
cause  is,  perhaps,  more  often  multiple  than  when  due  to  any  other. 


NON-MALIGNANT   STRICTURE   OF   THE   RECTUM.  253 


Inflammatory  or  so-called  SypMlitic  Stricture. 

Proctitis,  when  chronic  and  attended  by  sufficient  changes  in  the 
structure  of  the  coats  of  the  rectum,  will  result  in  stricture  ;  and 
so  may  any  inflammation  of  the  perirectal  tissues. 

It  is  to  this  cause  that  the  large  class  of  strictures  which  for 
many  years  have  been  classified  as  syphilitic  is  to  be  attributed. 
The  impossibilit}''  of  finding  any  venereal  cause  for  this  form  of  dis- 
ease in  a  great  many  cases  in  private  practice  will  be  admitted  by 
every  observer,  and  a  single  case  of  so-called  syphilitic  stricture  in 
which  the  existence  of  syphilis  is  manifestly  impossible  is  a  very 
hard  clinical  fact  to  overcome  by  theory.  I  have  seen  many  such, 
.and  so  have  others,  though  the  idea  that  a  virtuous  maiden  lady  of 
sixty  or  so,  may  have  contracted  syphilis  without  ever  having  been 
exposed  or  showing  any  evidence  of  the  disease  except  an  ulceration 
•of  the  rectum  following,  perhaps,  an  operation  for  hemorrhoids,  has 
been  generally  used  to  explain  them.  With  this  theory  I  have  no 
sympathy.  When  this  form  of  stricture  occurs  in  a  patient  who  has 
had  syphilis,  there  may  be  some  basis  for  supposing  that  it  may  be 
syphilitic,  though  I  do  not  believe  it  to  be  so  :  when  it  occurs  under 
•circumstances  which  make  the  previous  existence  of  syphilis  an  im- 
possibility, both  morally  and  clinically,  some  other  etiology  must  be 
found. 

Take,  for  example,  such  a  case  as  the  following. 

A  young  lady  of  sixteen  has  typhoid  fever  with  various  compli- 
cations. At  one  time  the  bowels  become  impacted  and  are  dug  out 
with  the  finger  and  a  spoon  by  a  nurse.  Great  pain  is  caused  at  the 
time  and  considerable  bleeding.  Never  after  that  is  the  girl  free 
from  pain,  and  bloody  discharge  from  the  rectum.  In  a  few  months 
a  fistula  forms  which  breaks  on  the  skin  and  also  causes  a  free  com- 
munication between  rectum  and  vagina.  An  examination  under 
ether  shows  advanced  destructive  ulceration  of  the  rectum,  tight 
stricture  and  a  nearly  imperforate  hymen.  A  colostomy  ends  fatally 
from  exhaustion  and  shock.  Setting  aside  preconceived  theories  is  it 
more  logical  to  suppose  that  this  stricture  was  caused  by  a  rough 
.attack  upon  the  rectum  with  a  spoon  or  by  a  ]a]ise  from  virtue  ? 


254 


SURGERY   OF   THE   RECTUM   AJSTD   PELVIS. 


Trauviatic  Stricture. 

A  simple  traumatism  may  result  in  stricture,  either  by  causing- 
ulceration  and  cicatrization  or  by  exciting  a  chronic  inflammation 
of  the  walls  of  the  rectum.  Amongst  these  traumatisms  may  be 
enumerated,  applications  of  strong  acids,  the  performance  of  some- 


FiG.  141. 
Stricture  from  Tubercular  Ulceration. 


surgical  operations,  foreign  bodies,  kicks  and  falls,  and  the  injury 
produced  by  the  head  of  the  child  at  birth. 

Tubercular  Stricture. — There  is  no  longer  any  doubt  in  my  own 
mind  that  tubercular  ulceration  may  result  in  sufficient  narrowing  of 
the  canal  to  produce  stricture.  I  have  seen  this  occur  too  palpably 
to  be  mistaken. 


NON-MALIGNANT   STRICTURE   OF   THE   RECTUM.  255 

Venereal  Stricture. — The  venereal  sores  capable  of  producing  a 
stricture  are  the  chancroid  and  the  later  syphilitic  ulcers.  We 
shall  leave  out  of  consideration  the  true  chancre  and  the  mucous 
patch,  for  the  reason  that  their  influence  in  the  causation  of  strict- 
ure is  still  rather  a  matter  of  surmise  than  of  proof,  and  the  same 
thing  may  be  said  regarding  gonorrhoea  of  the  rectum. 

For  a  description  of  these  ulcerative  venereal  processes  the  reader 
may  again  refer  to  the  last  chapter. 

PatJiological  Anatomy. 

In  studying  the  pathological  anatomy  of  stricture  there  are  sev- 
eral points  to  be  observed,  for  changes  will  be  found  not  only  at  the 
stricture  itself,  but  both  above  and  below  it,  and  in  the  surrounding 
parts. 

From  what  has  been  said  already,  it  will  be  inferred  that  a  strict- 
ure which  is  not  the  direct  result  of  a  deposit  of  new  material  in  the 
rectal  wall,  as  in  cancer,  will  be  composed  either  of  cicatricial  tissue, 
such  as  is  found  in  other  parts  of  the  body,  or  else  of  hypertrophied 
connective  tissue  which  is  firm  and  dense  and  creaks  under  the  knife 
on  section.  All  the  connective  tissue  in  the  rectum  at  the  diseased 
point,  whether  submucous,  subperitoneal,  or  intermuscular,  will  be 
found  to  have  increased  in  quantity,  and  this  accounts  for  the  in- 
creased thickness  of  the  rectal  wall.  The  mucous  membrane  at  the 
seat  of  stricture  will  generally  be  found  destroyed,  and  replaced 
by  granulation  tissue  on  this  fibrous  base,  which  bleeds  easily  when 
scraped. 

Above  the  constriction  a  process  occurs  which  will  be  found  to  be 
almost  constant.  This  begins  by  a  dilatation  of  the  bowel  and  an 
hypertrophy  of  the  muscular  layer,  with,  at  first,  a  thickening  of 
the  mucous  membrane.  Later,  the  mucous  membrane,  due  prob- 
ably to  the  irritation  of  retained  faeces,  will  show  all  the  stages  of 
ulceration,  from  simple  congestion  in  some  points  to  a  complete  de- 
struction in  others  and  an  exposure  of  the  muscular  tissue  beneath. 

This  ulcerative  process  may  extend  for  several  inches  up  the 
bowel.  The  wall  of  the  bowel  above  the  stricture  may  be  as  thin 
as  paper  in  spots,   and  at   such    points    perforation  is  apt  to  take 


256  SUEGERY   OF   THE   KECTUM   AND   PELVIS. 

place.  Fatal  perforation  from  this  cause  lias  happened  in  my  own 
practice  a  few  hours  after  excision  of  a  cancerous  stricture.  In  a  case 
reported  by  Goodhart,  the  changes  of  which  we  are  speaking  had 
gone  on  to  actual  gangrene,  extending  in  spots  along  the  transverse 
and  descending  colon,  and  were  undoubtedly  due  to  the  intensity  of 
the  inflammatory  action  caused  by  the  retained  irritant  matters.  The 
bowel  is  also  generally  distended  with  gas  and  faeces,  and  the  latter 
are  more  often  fluid  than  solid,  though  fecal  tumors,  with  their 
well-known  characteristics,  will  sometimes  be  met. 

The  dilatation  abo^e  the  stricture  may  reach  an  enormous  size, 
and  may  ultimately  result  in  2i  cul-de-sac  or  pouch  wdiich  will  fill  a 
large  portion  of  the  abdomen  and  dip  down  below  the  point  of  con- 
striction, and  an  ulceration  in  this  pouch  may  result  in  its  perfora- 
tion and  the  establishment  of  a  fistulous  outlet  for  the  faeces.  Such 
an  opening  may  be  into  the  rectum,  either  above  or  below  the 
stricture,  or  into  the  pelvis,  with  the  necessary  result  of  abscess.  An 
opening  may  also  be  made  into  the  bladder  in  either  sex,  and  in  fe- 
males into  any  part  of  the  genital  tract. 

The  cellular  tissue  in  the  ischio-rectal  fossae  around  a  stricture 
may  also  become  hard  and  lardaceous  as  a  result  of  chronic  inflam- 
mation ;  and  this  change  may  extend  to  some  distance  from  the 
original  starting-point  along  the  sacrum,  as  high  as  the  promontorj^, 
and  into  the  subperitoneal  tissue  of  the  iliac  fossae. 

Abscess  is  always  liable  to  occur  in  the  neighborhood  of  the 
stricture,  probably  from  lowered  vitalit}^  in  the  parts,  and  this  ac- 
counts for  the  relative  frequency  of  fistulae  in  this  disease.  These 
may  be  both  numerous  and  extensive,  and  may  make  communica- 
tions between  the  rectum  and  any  of  the  adjacent  organs. 

Below  the  stricture  the  rectum  may  sometimes  be  found  un- 
changed from  its  normal  condition,  but  it  wdll  general!}'  be  ulcerated 
as  it  is  above,  or  else  there  will  be  hemorrhoidal  tumors,  excoriations, 
and  vegetations  and  tags  of  larger  or  smaller  size.  These  growths 
are  the  result  simply  of  irritation  of  the  discharge  from  the  process 
above. 

Most  strictures  are  located  in  the  lower  part  of  the  rectum,  and 
hence  their  presence  is  easily  detected  in  the  majority  of  cases.  They 
are  said  to  be  far  more  frequent  in  females  than  in  males,  because 


NON-MALIGNANT   STRICTURE   OF  THE   RECTUM.  257 

many  of  the  causes  which  produce  them  operate  cliiefly  in  females, 
but  my  own  statistics  do  not  verify  this  idea.  Age  has  little  influ- 
ence upon  their  frequency  after  the  period  of  adult  life. 

A  stricture  may  or  may  not  involve  the  whole  circumference  of 
the  bowel ;  and  the  contraction  may  be  so  slight  as  not  to  be  apjjar- 
ent  till  the  bowel  is  distended  with  the  speculum,  when  a  falciform 
band  may  spring  out  from  one  side.  In  more  extensive  disease  there 
is  still  usually  a  passage  for  the  feeces,  but  this  may  be  very  slight. 
The  most  extensive  disease  will  be  found  to  be  due  generally  either 
to  dysentery  or  chronic  proctitis,  and  in  such  cases  the  calibre  of 
the  bowel  may  be  lessened  for  a  space  of  several  inches. 

Symptoms. 

These  may  be  grouped  under  two  heads,  those  due  to  ulceration 
and  those  due  to  mechanical  obstruction.  In  the  great  majority  of 
cases  the  signs  of  mechanical  obstruction  will  be  preceded  by  those 
of  the  ulceration  which  has  caused  it.  The  symptoms  of  ulceration 
of  the  rectum  are  diagnostic  and  have  already  been  described  under 
that  heading. 

The  one  positive  sign  of  a  stricture  is  the  obstruction,  and  this 
may  show  itself  in  several  ways,  generally  at  first  by  alternate  at- 
tacks of  constipation  and  diarrhoea.  The  constipation  is  mechan- 
ical, and  is  due  to  the  accumulation  of  faeces  above  the  constriction. 
The  diarrhoea  is  secondary  to  the  accumulation,  which  in  time  begins 
to  act  as  a  foreign  body,  setting  up  a  catarrhal  inflammation,  as  a 
result  of  which  sufficient  fluid  is  poured  into  the  bowel  to  soften 
the  hardened  mass,  and  large  quantities  are  discharged,  only  to  be 
followed  by  a  fresh  accumulation. 

It  has  often  been  asserted  that  a  well-marked  lessening  of  the 
rectal  calibre  must,  in  the  nature  of  things,  produce  a  change  in  the 
shape  of  the  faeces  ;  but  this  is  not  quite  true.  The  flattened,  tape- 
like stool  is  a  sign  of  value  when  present,  and  should  always  lead 
to  careful  exploration  ;  bat  it  may  not  be  present  even  in  the  worst 
cases  of  stricture,  and  it  may  exist  without  stricture,  in  the  latter 
case  being  due  to  an  irregular  spasmodic  action  of  the  sphincters. 

It  is  well  known  that,   with  the  closest  stricture  high  up,   the 

17 


258  SURGEEY   OF   THE   RECTUM    AND   PELVIS. 

faeces  may  be  reformed  in  the  rectum  below  and  be  passed  normal  in 
size.  At  the  bedside  but  little  importance  is  to  be  attached  to  the 
statements  of  patients  concerning  this  matter. 

After  a  stricture  has  existed  for  a  certain  length  of  time,  signs  of 
obstruction  may  be  manifest  b}^  abdominal  palpation  and  inspection. 
The  transverse  and  descending  colon  can  be  felt  partially  distended 
with  masses  of  fseces,  which  will  be  dull  on  percussion,  tender  to  the 
touch,  somewhat  movable,  and  pitting  on  firm  pressure.  After  an 
attack  of  diarrhcea,  or  after  a  brisk  purge,  these  accumulations  may 
disappear,  only  to  form  again  in  a  short  time. 

The  condition  of  chronic  obstruction  with  its  attendant  evils — 
dilatation  of  the  bowel  and  intestinal  catarrh  above  the  obstruction, 
with  ulceration  and  thinning  of  the  intestinal  wall— is  thus  insensi- 
bly established.  One  who  sees  many  of  these  cases  of  chronic  ob- 
struction, and  knows  how  dilated  and  weakened  the  bowel  may  be- 
come above  the  stricture,  will  be  very  cautious  in  the  use  of  cathar- 
tics in  this  condition. 

Acute  obstruction  may  at  any  time  be  added  to  the  chronic  con- 
dition ;  but  acute  and  complete  obstruction  are  comparatively  rare  in 
stricture  of  the  rectum  ;  and  acute  obstruction  as  the  first  symptom 
of  the  disease,  without  the  previous  history  of  ulceration,  is  rarer 
still.  In  my  own  experience  I  have  seen  acute  complete  obstruction 
supervene  upon  the  chronic  condition  in  but  few  cases,  two  ending 
fatally  in  rupture  of  the  colon,  and  the  others  relieved  by  operation. 

Acute  obstruction  as  the  first  and  only  sj^uptom  of  stricture  I 
have  seen  but  once— a  case  of  cancer  between  the  promontory  of  the 
sacrum  and  rectum,  occluding  the  latter  by  direct  pressure.  In  one 
other  case  acute  obstruction  ended  fatally  before  there  were  sufficient 
symptoms  of  rectal  disease  to  enable  us  to  make  a  diagnosis  ;  the 
patient,  a  physician,  complaining  only  of  pain  in  the  left  iliac  fossa, 
and  of  occasional  passages  of  blood  with  the  fseces.  The  autopsy 
revealed  an  annular  cancerous  stricture  in  the  sigmoid  flexure. 

Generally  complete  obstruction  does  not  occur  without  ample 
warning.  It  is  more  apt  to  appear  suddenly  where  the  stricture  is 
high  up  in  the  rectum  or  at  the  Junction  with  the  sigmoid  flexure. 

It  comes  on  with  the  usual  signs  of  acute  intestinal  strangulation 
— pain,  swelling  of  the  abdomen,  bloody  passages,  etc. — and  it  may 


NON-MALIGlSrANT   STRICTURE   OF   THE   RECTUM.  259 

be  caused  by  some  indigestible  substance  which  lias  been  swallowed 
and  refuses  to  pass  the  stricture,  or  merely  by  hardened  faeces  or 
prolapse  of  the  bowel  above  into  the  constriction. 

There  is  one  important  element  in  the  obstruction  due  to  stricture 
which  must  not  be  forgotten.  It  will  sometimes  happen  that  fatal 
obstruction  will  occur  even  when,  on  post-mortem  examination,  the 
calibre  of  the  stricture  is  found  to  be  large  enough  to  permit  the 
passage  of  the  finger,  showing  that  the  obstruction  could  not  have 
been  due  merely  to  the  contraction  of  the  new  growth. 

The  explanation  of  the  condition  is  not  difficult.  Stricture  high 
up  in  the  rectum  is  much  more  dangerous  and  liable  to  cause  sudden 
and  complete  obstruction  than  when  low  down,  on  account  of  the 
greater  mobility  of  the  gut.  Thus  we  constantly  see  patients  going 
for  years  with  stricture  in  the  lower  three  inches  of  the  gut,  the 
calibre  of  which  is  so  small  as  to  cause  constant  wonder  at  the  escape 
of  any  solid  faeces ;  while,  on  the  other  hand,  we  occasionally  meet 
with  sudden  death  from  obstruction  in  stricture  higher  up,  where  the 
amount  of  contraction  does  not  seem  sufficient  to  cause  such  result. 

The  fact  is  that  a  very  small  outlet  will  answer  the  purpose  when 
the  orifice  is  fixed,  and  the  whole  muscular  power  exerted  in  straining 
can  be  brought  upon  this  fixed  point.  When,  on  the  other  hand, 
the  outlet  is  not  fixed  by  surrounding  tissues,  the  gut  bends  on 
itself,  the  outlet  is  no  longer  in  the  axis  of  the  force  used,  and  the 
more  the  force  the  greater  the  obstruction  due  to  flexure  of  the 
canal. 

Stricture  of  the  rectum,  whether  cancerous  or  benign,  left  to  its 
own  course,  ends  fatally,  either  by  obstruction  or  by  exhausting  the 
sufferer's  powers.  After  a  few  years  these  patients  sink  into  a  mis- 
erable condition,  worn  out  by  constant  rectal  tenesmus,  by  chronic 
intestinal  obstruction,  and  by  degeneration  of  the  kidneys. 

Diagnosis. 

The  first  means  of  diagnosis  in  stricture  is  the  examination  with 
the  finger  ;  and,  as  the  majority  of  strictures  are  confined  to  the 
lower  portion  of  the  rectum,  this  is  in  itself  often  sufficient.  It  is  the 
best  and  safest  and  least  painful  of  all  the  means  of  diagnosis  Avhen 


260  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

properly  executed,  and  yet  it  may  be  the  immediate  cause  of  death 
to  the  patient  when  roughly  practised. 

There  is  an  inborn  tendency  on  the  part  of  many,  when  the  index 
finger  comes  in  contact  with  a  tight  stricture,  to  bore  through  the 
narrow  passage  which  is  left  and  feel  what  is  on  the  other  side — a 
tendency  to  be  struggled  against  and  overcome.  If  the  surgeon  has 
deliberately  determined  to  practise  divulsion,  this  is  one  way  to  do 
it  ;  but  at  present  we  are  speaking  of  diagnosis,  and  forcible  dila- 
tation is  not  diagnosis,  but  a  very  grave  surgical  procedure. 

The  finger  should  therefore  be  passed  slowly  up  to  the  stricture, 
and,  unless  the  calibre  admits  of  it  without  straining,  it  should  not 
be  passed  farther.  The  condition  of  the  parts  below  may  also  be 
appreciated,  the  amount  of  induration  estimated,  and  a  general  idea 
formed  of  the  nature  and  extent  of  the  disease.  In  women  the 
vaginal  touch  will  generally  be  found  of  the  greatest  value  and 
should  never  be  omitted. 

As  a  rule,  all  can  be  learned  in  this  way  that  can  be  learned  in 
any  other  where  the  disease  is  within  reach  of  the  finger,  and  nothing 
is  to  be  gained  by  a  painful  speculum  examination  or  the  use  of 
the  bougie — means  of  diagnosis  which,  however  valuable  where  the 
stricture  cannot  be  felt  by  the  finger,  are  of  little  use  for  the  lower 
four  inches  of  the  rectum. 

When  a  stricture  is  situated  high  up  in  the  rectum  or  in  the  sig- 
moid flexure,  the  confidence  in  diagnosis  which  comes  from  actual 
contact  of  the  finger  with  the  disease  is  entirely  lost,  and  there  is 
perhaps  nothing  in  the  whole  range  of  surgical  diagnosis  which  re- 
quires more  skill  than  the  detection  of  stricture  in  this  part,  and 
nothing  attended  with  more  uncertainty. 

A  stricture  in  the  locality  in  question  must  be  examined  for  with 
the  greatest  care  and  gentleness,  and  the  examination  will  often  be 
negative  in  its  results.  The  attempt  to  decide  the  question  by  the 
use  of  bougies  is  not  always  satisfactory  and  by  no  means  free  from 
danger.  It  is  unsatisfactory  to  the  general  practitioner,  because  an 
obstruction  will  generally  be  encountered  in  trying  to  pass  an  instru- 
ment of  any  considerable  size  through  this  part  of  the  bowel,  and  the 
passage  of  an  instrument  of  small  size,  which  is  much  easier,  proves 
nothing.     It  is  dangerous  because  a  diseased  bowel  may  easily  be 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  261 

ruptured  with  wliat  may  seem  to  tlie  operator  to  be  no  more  force 
than  is  justified  in  attempting  to  overcome  the  natural  obstructions 
in  this  part  of  tlie  passage. 

If  a  hollow,  soft  rubber  bougie  is  used  for  exploration,  the  open- 
ing at  the  lower  end  should  be  of  a  size  to  admit  the  small  tube  of  a 
Davidson  syringe,  which  should  be  fitted  to  it  before  the  attempt  to 
pass  it  is  begun.  Then,  with  a  basin  of  warm  water  close  at  hand, 
the  bougie  may  be  introduced,  and  at  the  first  obstruction  the  bowel 
should  be  filled  with  water  until  it  is  moderately  distended.  In  this 
way  the  folds  of  mucous  membrane  are  drawn  out  of  the  way  by 
the  distention  of  the  whole  bowel,  and  one  great  obstacle  is  elimi- 
nated. The  next  is  the  promontory  of  the  sacrum,  which  is  much 
more  easily  passed  by  a  soft  than  by  a  stiff  instrument.  Without 
these  precautions,  and  sometimes  with  them,  the  inexperienced  ex- 
aminer will  find  a  stricture  in  the  rectum  of  nineteen  persons  out 
of  twenty,  no  matter  how  healthy  they  ma}  be  ;  and  for  this 
reason  it  is  seldom  safe  to  rest  the  diagnosis  of  stricture  on  the 
fact  that  a  bougie  cannot  be  made  to  pass.  Moreover,  a  bougie  of 
good  size  will  often  pass  a  stricture  small  enough  to  produce  great 
trouble. 

The  sound  made  by  Dr.  Andrews,  and  described  in  the  chapter  on 
Exploration,  is  of  greater  value  than  the  flexible  rubber  instrument, 
though  more  dangerous  in  unskilled  hands.  For  my  own  part,  if  I 
could  pass  no  bougie  at  all  after  proper  trials,  and  if,  under  ether,  I 
still  failed  to  effect  the  passage  of  an  instrument,  I  should  not  hesi- 
tate to  make  a  positive  diagnosis  of  a  very  tight  stricture.  Also,  if  a 
medium-sized  bougie,  say  No.  7,  passed  easily,  but  a  No.  8  could  not 
be  passed,  and  the  symptoms  pointed  to  old  ulceration  of  the  intes. 
tine,  I  should  diagnosticate  a  contraction,  but  I  should  not  do  so  till 
after  several  careful  trials  with  the  instruments. 

It  is  in  just  these  cases  that  high  exploration  of  the  rectum  with 
reflected  light  and  a  long  cylindrical  speculum  may  be  of  great  bene- 
fit. There  is  danger  in  its  use,  however,  for  a  fatal  laceration  may  as 
easily  be  caused  by  pushing  against  a  stricture  as  by  forcing  a  way 
through  it. 

Should  the  symptoms  justify  it,  an  exploratory  laparotomy  is 
always  in  order,  and  should  be  made  as  for  left  inguinal  colostomy, 


262  SURGEEY   OF   THE   RECTUM   AND   PELVIS. 

in  order  that  an  artificial  anus  may  be  established  at  the  same  time, 
should  a  stricture  be  discovered. 

After  the  presence  of  stricture  has  been  decided  upon,  the  deter- 
mination of  its  character  may  also  be  a  matter  of  great  difficulty. 

As  a  first  step  in  the  differential  diagnosis  between  malignant  and 
non-malignant  stricture,  the  length  of  time  the  disease  has  existed 
is  of  great  practical  help.  Cancer  of  the  rectum  generally  runs  its 
course  in  two  or  three  years.  When,  therefore,  a  patient  says  strict- 
ure and  ulceration  have  existed  ten,  fifteen,  or  twenty  years,  a  great 
point  has  been  gained.  When,  on  the  other  hand,  a  middle-aged 
patient  says  that  the  symptoms  date  back  only  a  few  months,  and 
an  examination  reveals  masses  of  hard  tissue  occluding  the  bowel, 
with  more  or  less  destructive  ulceration,  the  disease  can  hardly  be 
other  than  malignant. 

By  careful  attention  to  the  histor}^  alone,  the  nature  of  the  affec- 
tion can  thus  very  often  be  determined. 

In  other  cases  digital  examination  alone  is  sufficient  for  the  differ- 
ential diagnosis.  Generally  cancer  in  the  rectum  presents  itself  to 
the  sight  and  touch  as  a  mass  of  stony  hardness,  nodular,  irregular, 
and  without  pedicle  ;  growing  in  the  substance  of  the  rectal  wall  and 
involving  all  adjacent  tissue  ;  with  no  tendency  to  isolate  itself  and 
hang  free  in  the  cavity  of  the  gut.  More  rarely  it  is  seen  in  the  form 
of  a  deep  ulceration  with  hard  floor  and  raised  hard  edges— an  ulcer- 
ation so  pronounced  and  so  destructive  as  to  leave  no  room  for  doubt 
as  to  its  nature.  Again  it  not  infrequently  presents  itself  as  a  bleed- 
ino;,  fungous  mass  involving  the  whole  substance  of  the  rectal  wall, 
filling  and  occluding  the  gut,  and  perhaps  extruding  at  each  act  of 
defecation. 

In  either  of  these  three  clinical  forms  the  gross  characteristics  are 
diagnostic,  and  with  experience  it  is  not  generally  difficult  to  decide 
between  malignant  and  non-malignant  disease.  The  cases  most 
doubtful  are  those  where  the  rectum  is  occluded  by  dense  masses  of 
fibrous  tissue.  In  these  the  amount  of  disease  may  be  as  great  as,  or 
greater  than,  in  cancerous  infiltration,  and  the  hardness,  to  the  touch 
may  be  the  same  ;  but  the  history  of  the  case  and  the  length  of  time 
it  has  existed  will  generally  solve  the  question. 

Enlarged  glands  in  the  groin  or  hollow  of  the  sacrum  are  of  great 


NOIST-M  ALIGN  ANT   STRICTURE   OF   THE    RECTUM.  263 

value  when  found,  and  we  always  have  the  microscope  to  appeal  to 
in  case  of  doubt. 

I  would  not,  however,  give  the  impression  that  this  diagnosis  be- 
tween benign  and  malignant  disease  can  always  be  made  absolutely, 
either  by  the  history  or  by  digital  examination,  for  such  is  not  my 
experience,  and  I  am  occasionally  very  glad  to  secure  a  piece  of  the 
growth  for  microscopic  examination  before  committing  myself  to  a 
positive  diagnosis. 

The  odor  of  cancer  I  have  never  been  able  to  distinguish  as  any- 
thing diagnostic,  and  I  confess  to  a  feeling  of  relief  when  in  Cripps's 
monograph  on  this  subject  I  find  that  he  also  appreciates  that  in 
some  cases  the  diagnosis  may  be  difficult. 

Greater  difficulty  may  be  found  in  the  differential  diagnosis  of 
the  different  forms  of  non-malignant  stricture  from  each  other  than  in 
deciding  the  first  great  question  of  cancer. 

Dysenteric  contraction  is  known  by  the  history  and  often  by  the 
extensive  character  of  the  fibrous  induration.  Tubercular  disease 
may  first  be  suspected  from  the  patient's  general  condition,  from  the 
coexistence  of  lung  trouble,  or  the  family  history  ;  and  the  diagnosis 
may  then  be  confirmed  under  the  microscope. 

In  congenital  stricture  in  adult  life  the  existence  of  a  knife-edge 
constriction  without  ulceration  or  induration  is  diagnostic.  Strict- 
ures resulting  from  slight  traumatism,  such  as  operations  for  hemor- 
rhoids, may  be  recognized  by  the  absence  of  any  other  exciting 
cause,  as  syphilis,  and  by  the  history  of  long-continued  ulceration. 

TreatTRent. 

The  treatment  of  stricture  of  the  rectum  is  chiefly  surgical.  If 
a  man  still  believes  that  all  strictures  not  cancerous  are  syphilitics, 
he  must  use  antisyphilitic  treatment,  and  in  most  cases  he  will  find 
it  will  have  no  effect  upon  the  local  condition. 

It  is  well  to  exercise  caution  in  this  matter,  however,  for  the  gen- 
eral condition  of  these  patients  is  never  up  to  the  normal,  and  a 
severe  course  of  constitutional  treatment  may  be  productive  of  harm. 

There  are  various  means  by  which  the  comfort  of  these  sufferers 
may  be  greatly  increased  without  recourse  to  operative  treatment ; 


264  SURGEKY    OF   THE   RECTUM   AND   PELVIS. 

and  since  in  many  cases  tlie  surgeon  is  limited  to  these  means  in  liis 
efforts  to  afford  relief,  it  is  well  that  they  should  receive  careful  at- 
tention. The  most  effectual  of  them  will  be  found  to  be  a  careful 
regulation  of  the  diet,  the  administration  of  laxatives  on  occasion, 
and  rest.  The  diet  should  consist  mostly  of  fluids,  preferably  milk. 
If  milk  is  complained  of,  or  causes  large,  solid  passages,  soups  may 
be  substituted.  A  certain  amount  of  farinaceous  food  may  also  be 
allowed,  such  as  toast  and  crackers  ;  but  milk  is  the  basis  of  the  diet, 
and  the  other  things  are  only  intended  to  make  that  diet  endurable. 
Many  patients  will  assert  from  the  outset  that  they  cannot  take 
milk,  and  this  will  occasionally  be  found  true,  but  nearly  all  can 
take  it,  and  considerable  quantities  of  it  daily  for  an  indefinite 
period,  if  a  little  care  is  exercised  in  its  administration. 

The  bowels  should  move  daily  without  straining.  Should  any 
medication  be  necessary  to  secure  this  daily  evacuation,  a  mild  laxa- 
tive will  be  found  all-sufficient.  The  mineral  waters  or  Rochelle 
salts  answer  every  purpose.  One  of  the  most  grateful  ways  to  these 
sufferers  of  moving  the  bowels  is  to  administer  an  enema  of  warm 
water  through  a  long  tube  which  will  reach  above  the  stricture. 

Purgatives  are  always  contra-indicated  in  stricture  of  any  variety, 
because  they  cause  straining  and  tenesmus,  increase  the  tendency  to 
congestion  and  its  consequences,  and  because  where  obstruction 
actually  exists  or  is  threatened  they  may  do  great  harm  by  exciting 
violently  peristaltic  action  in  an  already  weakened  and  ulcerated 
bowel.  The  opposite  condition  of  diarrhoea  is  more  difficult  to  meet, 
and  often  cannot  be  controlled  by  direct  medical  treatment,  depend- 
ing, as  it  does,  on  the  ulceration  associated  with  the  stricture.  It  is 
best  met  by  diet,  rest  in  the  recumbent  posture,  and  bismuth  with 
morphine. 

The  general  strength  of  these  patients  is  to  be  supported  in  every 
possible  way,  and  in  all  of  them  where  it  can  be  borne  cod-liver  oil 
will  be  found  to  answer  a  good  purpose. 

When  obstruction  actually  exists,  operation  is  of  course  indi- 
cated, but  much  may  be  done  in  the  way  of  general  treatment  before 
resorting  to  operation.  Food  by  the  mouth  should  be  given,  if 
possible,  and  opium  in  large  doses  to  allay  the  violent  peristalsis.  In 
more  than  one  case  of  complete  obstruction  I  have  secured  an  action 


NON-MALIGWANT   STRICTURE   OF   THE   RECTUM.  265 

of  the  bowels  after  producing  complete  opium  narcosis.  No  purga- 
tives should  be  given.  Tapping  the  distended  coils  of  gut  with  a  fine 
, aspirator  needle  has  also  saved  life  in  my  own  practice,  but  these 
things  are  only  to  be  thought  of  when  a  laparotomy  cannot  for  any 
reason  be  performed. 

The  surgical  means  at  our  command  for  the  treatment  of  this  af- 
fection are  :   Dilatation^  incision^  excision.,  colostomy. 

Dilatation. 

This,  either  alone  or  in  connection  with  incision,  is  one  of  the 
most  reliable  agents  for  the  treatment  of  stricture.  By  dilatation  I 
mean  gradual  stretching,  not  forcible  divulsion.  The  latter  is  a  jus- 
tifiable procedure  ;  one  which  under  certain  conditions  may  accom- 
plish great  good,  but  one  seldom  applicable. 

Whether  dilatation  be  practised  as  an  independent  method  of 
treatment  or  as  a  supplement  to  division,  it  should  always  be  prac- 
tised in  one  way.  Nothing  is  productive  of  more  evil  than  forcing 
a  bougie  through  a  stricture  when  the  instrument  is  too  large  to  be 
passed  without  pain  and  violence,  and  no  good  is  ever  accomplished 
in  this  way. 

A  bougie  that  is  large  enough  to  cause  pain  by  stretching  is  al- 
ways too  large  to  do  anything  but  harm. 

The  instrument  best  adapted  for  this  purpose  is  the  soft-rubber 
one.  A  size  should  be  selected  which  will  pass  through  the  stricture 
without  force  and  which  may  be  left  in  place  several  hours  without 
causing  uneasiness.  In  this  way  absorption  of  the  stricture  tissue 
may  be  caused,  and  great  benefit  may  result.  It  is  a  well-known  fact 
that  if  the  smallest  filiform  bougie  be  passed  through  a  stricture  of 
the  urethra  and  allowed  to  remain  for  a  da}^  or  two,  a  much  larger 
size  can  then  be  substituted  for  it ;  and  the  same  is  true  of  the  rectum. 
Any  instrument  the  introduction  of  which  causes  pain  will  soon  cause 
so  much  irritation  as  to  render  its  use  impossible  ;  while  with  gentle- 
ness and  time  most  non-malignant-strictures  may  be  greatly  benefited. 

When  the  disease  is  so  high  up  that  the  long  bougie  is  necessary, 
its  introduction  should  never  be  left  either  to  patient  or  nurse  ;  for 
even  with  the  soft-rubber  one  mentioned  great  harm  may  be  done.  In 


266  SURGERY   OF   THE   RECTUM   AN'D   PELVIS. 

cases  where  the  disease  is  nearer  the  anus  I  have  had  these  same 
instruments  made  five  inches  long  instead  of  twelve,  and  these  may 
safely  be  entrusted  to  the  patient.  They  are  numbered  in  sizes  from 
one  to  twelve.  • 

The  treatment  by  gentle  dilatation  will  accomplish  most  in  cases  of 
limited  severity  and  as  a  supplement  to  the  treatment  by  incision. 
Most  of  the  old  fibrous  strictures  are  too  extensive  to  be  relieved  in 
this  way,  and  in  malignant  disease  it  does  harm. 

Incision. 

The  treatment  of  stricture  by  linear  proctotomy  was  introduced 
by  the  French  surgeons,  and,  judged  by  their  first  enthusiastic 
reports,  it  seemed  that  by  it  alone  a  radical  cure  could  be  effected. 
Subsequent  experience  has  convinced  me  that  such  is  not  the  case,  and 
that,  like  the  analogous  operation  of  external  urethrotoni}^,  it  must  be 
followed  by  dilatation  to  preserve  the  channel  opened  up  by  the 
knife.  As  a  means  of  saving  time,  and  of  gaining  a  wider  passage 
than  can  be  hoped  for  from  the  bougie  alone,  it  is  of  great  value. 

Two  operations  are  spoken  of — internal  and  external  posterior 
linear  proctotomy.  The  internal  consists  simply  of  a  division  of  the 
stricture  tissue  alone  by  an  incision  in  the  median  line  behind,  the 
cut  being  deep  enough  to  completely  divide  all  of  the  fibrous  tissues. 
The  external  operation  does  this  and  more,  inasmuch  as  it  divides 
not  only  the  stricture,  but  also  all  of  the  tissue  between  it  and  the 
anus,  with  the  sphincters,  and  thus  allows  drainage  and  avoids  one 
of  the  great  dangers  of  septic  periproctitis. 

The  originators  of  this  operation  employed  either  the  Paquelin 
cautery  knife  or  the  chain  ecraseur  for  the  incision,  both  of  them 
being  bloodless  ;  and  in  my  own  first  cases  I  used  the  cautery.  But 
the  bleeding  with  the  external  operation  is  not  a  matter  to  be  feared, 
being  easily  controlled  by  packing  the  incision  ;  and  I  now  use  a 
straight,  blunt -pointed  bistoury,  passed  into  the  bowel  and  through 
the  stricture  on  the  left  index  finger  as  a  guide. 

Care  should  be  taken  to  have  the  incision  reach  well  above  and 
well  through  all  the  stricture  tissue,  and  to  be  as  nearly  as  possible 
in  the  median  line  behind. 


NON-MALIGNANT   STRICTURE   OF   THE   RECTUM.  267 

The  danger  of  subsequent  incontinence  from  tliis  incision,  if  the 
sphincters  are  in  good  condition  when  it  is  made,  is  not  very  great ; 
but  tlie  wound  at  the  anus  generally  takes  many  weeks  to  heal,  and 
this  is  a  great  objection  to  it.  There  are  two  ways  of  avoiding  this. 
One  is  to  confine  the  incision  to  the  stricture,  leaving  the  anus  intact, 
and  to  drain  this  incision  by  a  tube  brought  out  through  the  skin  at 
tlie  tip  of  the  coccyx.  This  I  have  tried  in  several  cases,  with  tlie 
result  of  saving  much  time.  The  tube  should  be  left  in  till  all  dan- 
ger of  periproctitis  has  passed.  If  there  be  no  rise  of  temperature 
by  the  fourth  day  it  may  be  safely  removed,  and  the  wound  caused 
by  it  will  generally  heal  promptly. 

Another  method  I  have  sometimes  used  is  to  divide  the  sphinc- 
ters and  then  employ  three  or  four  deep  provisional  wire  sutures  be- 
tween the  anus  and  the  stricture,  leaving  them  loose  and  stuffing  the 
incision  with  charpie.  When  all  danger  is  past  and  granulation  is 
well  under  way,  the  opposing  surfaces  are  scraped  and  the  sutures 
tightened.  This  may  be  done  at  about  the  end  of  the  first  week, 
and,  as  more  or  less  firm  union  is  pretty  sure  to  result,  considerable 
time  is  saved. 

The  one  great  danger  of  this  operation  is  septic  periproctitis,  and, 
though,  with  proper  precautions  as  to  antisepsis  and  drainage  this 
may  be  greatly  lessened,  it  can  never  be  entirely  eliminated.  The 
danger  of  primary  hemorrhage  is  not  great.  No  large  vessels  are 
cut,  and  all  bleeding  is  within  easy  reach.  Secondary  hemorrhage  I 
have  seen  once  in  a  case  of  very  extensive  cancer  divided  with  the 
cautery. 

The  after-treatment  consists  only  in  the  use  of  the  bougie,  com- 
menced as  soon  as  the  incision  has  begun  to  fairly  close  ap— that  is 
to  say,  after  three  or  four  weeks— and  followed  steadily  and  gently, 
as  already  indicated.  The  bougie  should  be  used  for  three  or  four 
hours  each  day,  or,  as  is  my  favorite  practice,  introduced  when  the 
patient  goes  to  bed  and  left  in  all  night. 

In  the  great  majority  of  cases  the  short  instrument  will  reach 
above  the  disease,  and  after  one  or  two  trials  its  use  may  be  left  to 
the  patient.  If  pain  is  complained  of  it  is  a  sure  indication  that 
the  instrument  is  too  large  and  is  doing  harm. 

My  own  experience  with  this  method  has  been  considerable,  and 


268  SURGEllY    OF   THE   RECTUM   AND    PELVIS. 

neither  theoretically  nor  from  experience  can  I  recommend  it  in 
malignant  disease.  The  danger  of  it  is  certainly  greater  than  that  of 
a  colostomy,  and  nothing  more  than  temporary  slight  benefit  can  be 
hoped  for,  as,  in  the  nature  of  the  case,  subsequent  dilatation  can  do 
little  good. 

While  proctotomy  must  always  be  unsatisfactorj^  in  malignant 
disease,  exactly  the  opposite  has  been  the  case  in  benign  strictures, 
and  here  I  have  never  had  occasion  to  regret  its  performance.  For 
all  cases  of  non-malignant  stricture  which  are  not  so  far  beyond  the 
reach  of  local  treatment  that  either  excision  or  colostomy  is  indi- 
cated from  the  first,  this  plan  of  treatment  will  be  found  to  give  the 
best  results  and  the  nearest  possible  approach  to  a  cure. 

I  have  recently  performed  colostomj^^  on  a  patient  for  whom  I  did 
proctotomy  nine  years  ago,  and  who  for  five  years  after  the  oper- 
ation was  in  a  greatly  improved  condition,  though  at  that  time  most 
men,  I  think,  would  have  considered  her  beyond  hope  of  relief  from 
anything  except  a  colostomy,  so  grievous  was  her  condition.  She, 
however,  gained  health  and  strength,  and  was  able  to  keep  the  strict- 
ure well  under  control  till  about  two  years  ago,  when  a  large  pelvic 
abscess  formed  on  the  left  side,  nearly  occluding  the  gut  above  the 
original  stricture,  and  discharging  large  quantities  of  pus  into  the 
rectum.  For  this  second  condition,  together  with  the  old  stricture, 
I  did  the  colostomy,  as  the  combination  was  rapidly  exhausting  her. 

Other  cases  I  have  now  under  observation  in  which  the  patients 
have  been  so  greatly  improved  that  they  consider  themselves  entirely 
cured — cases  in  which  all  straining,  tenesmus,  and  purulent  discharge 
have  ceased,  and  in  which  the  patients  have  one  natural,  painless 
passage  daily,  but  these  have  been  cases  of  not  too  extensive  destruc- 
tion which  have  come  under  treatment  comparatively  early. 

Excision  and  Colostomy. 

In  the  severe  cases  of  non-malignant  stricture,  and  ulceration,  with 
or  without  stricture,  we  are  forced  either  to  excision  or  colostomy. 
Excision  is  certainly  the  ideal  method  of  treatment,  as  by  it  we  cure 
our  patient,  but  generally  at  the  expense  of  subsequent  incontinence. 
Still  it  is  to  be  remembered  that  these  patients  seldom  have  any  real 


JSrON-MALIGNANT   STRICTUEE   OF   THE   RECTUM. 


269 


sphincteric  power  by  the  time  the  disease  has  advanced  to  a  point  to 
make  excision  necessaiy,  and  that  when  the  discharge  and  conse- 
quent running  to  the  closet  have  been  cured  by  the  operation  they 
are  generally  fully  as  comfortable  in  this  regard  as  before  the  oper- 
ation. In  choosing  between  excision  and  colostomy  we  have  to 
choose  between  a  comparatively  severe  and  difficult  operation,  and 
one  of  slight  risk,  but  which  leaves  a  disgusting  deformity.  The 
patient  and  surgeon  must  work  out  the  answer  for  themselves  in 
each  case.  Personally  I  am  doing  many  more  extirpations  than 
colostomies  for  non-malignant  disease,  and  the  patients  are  much 
better  satisfied  with  an  anus,  even  though  it  be  an  imperfect  one,  in 
the  perineum  than  in  the  abdomen. 

Were  the  technique  of  excision  only  sufficiently  perfect  to  insure 
subsequent  control  of  the  evacuations  it  would  be  the  preferable  pro- 
cedure in  a  large  majority  of  cases. 

Intestinal  Anastomosis  Around  Stricture. 

The  following  method  of  treating  stricture  by  intestinal  anasto- 
mosis, devised  by  Bacon,  seems  worthy  of  further  trial.  It  consists 
in  forming  a  new  channel  around  the  stricture  by  folding  the  gut 
immediately  above  the  constricted  portion  of  the  bowel  down  over 


Fig.  142. 

Anastomosis  around  Stricture. 


270 


SURGERY    OF   THE   RECTUM    AND    PELVIS. 


the  stricture  and  anastomosing  it  with  the  rectum  just  below  the 
narrowed  part  of  the  gut,  then  at  a  subsequent  operation  clamping 
away  the  septum  that  has  been  formed  by  the  union  of  the  approxi- 
mated surfaces  of  the  folded  piece  of  gut  with  the  rectal  wall.  (Fig. 
142.) 

By  this  means  the  cicatricial  stricture-band  may  be  completely 
severed  and  kept  from  reforming,  because  the  healthy  gut  utilized  in 
building  a  new  channel  around  the  stricture  acts  as  a  connecting-link 
between  the  two  ends  of  the  stricture-band  that  is  severed  by  the 
clamp.  The  irritation  is  removed  and  the  cicatricial  mass  is  gradu- 
ally absorbed. 

The  anastomosing  of  the  bowel  above  the  stricture  with  the  bowel 
below  would  in  no  case  be  of  more  than  a  temporary  benefit,  because 
the  extensive  amount  of  fibrinous  connective  tissue  in  the  rectal  wall 
would  soon  contract  and  cause  fecal  impaction. 

The  clamping  away  of  the  newly  formed  septum  (Fig.  143,  A  to 
B)  is  the  most  important  part  of  the  operation,  for  by  this  means 
the  new  channel  is  added  to  the  calibre  of  the  rectum  (B  to  D,  Fig. 
143),  and  all  fecal  obstruction  is  removed. 

As  most  rectal  strictures  involve  the   levator  ani,  the  anastomo- 


FiG.  143. 
Clamping  away  Stricture. 


sis  could  not  be  made  by  any  device  requiring  sutures,  and  is  only 
possible  by  the  use  of  the  Murphy  button. 

The  operation  is  performed  as  follows  : 

After  complete  anaesthesia  the  patient  is  placed  in  the  extreme 


JSTON-MALIGNANT    STRICTURE    OF   THE    RECTUM.  271 

Trendelenburg  posture,  and  a  laparotomy  is  made  in  the  median  line 
from  tlie  pubis  to  the  umbilicus.  This  incision  will  enable  the 
operator  to  see  the  rectum  and  measure  the  extent  of  the  contrac- 


PiG.   144. 

Anastomosis  around  Stricture  of  Rectum. 

Line  ^  to  ^  represents  the  lower  limit  of  the  levator  ani. 
Z>,  the  anastomosis  buttons  in  position  after  sacral  section. 

tion,  and  to  decide  how  much  of  the  sigmoid  he  must  use  to  fold 
over  the  stricture  and  anastomose  below. 

Having  determined  the  amount,  the  sigmoid  is  drawn  well  up 
into  the  abdominal  wound,  and  an  assistant  places  a  small  Murphy 
clamp  above  and  below  that  point  of  the  gut  selected  for  the  anasto- 
mosis button.  An  incision  is  now  made  into  the  gut  and  the  male 
half  of  the  button  firmly  secured  in  position  in  the  usual  way. 


272  SUKGIi:RY   OF   THE   EECTUM   AND   PELVIS. 

The  next  step  in  the  operation  is  to  place  the  female  half  of  the 
button  in  position  just  below  the  stricture,  and  is  done  as  follows  : 
An  assistant  takes  the  instrument  (Fig.  145),  places  the  female  half 
of  the  button  over  the  trocar-point,  and  inserts  the  button  through 
the  anus  and  up  the  rectum  to  the  lower  border  of  the  stricture  ; 
keeping  the  point  of  the  trocar  guided  anteriorly,  he  presses  against 
the  anterior  rectal  wall.  The  operator,  by  feeling  down  the  pelvis 
through  the  abdominal  incision,  readily  finds  the  point  of  the  trocar, 
and  by  pressing  directly  over  it  with  a  pair  of  dressing  forceps,  the 


Fig.  145. 
Trocar  for  introducing  Murphy's  Button. 

trocar  perforates  the  rectal  wall  and  carries  the  neck  of  the  button 
with  it. 

This  half  of  the  button  is  now  seized  by  the  operator's  left  hand 
and,  taking  the  male  half  in  his  right,  the  two  halves  are  approxi- 
mated and  the  anastomosis  completed. 

Sutures  are  now  put  in  the  peritoneal  layer  of  the  gut  at  CC  (Fig. 
143),  so  as  to  hold  them  in  apposition  and  secure  firm  union  and 
form  the  septum  (A  to  B,  Fig.  143) ;  also  to  prevent  the  possibility 
of  a  loop  of  small  intestine  getting  between  the  approximated  sur- 
faces. 

The  button  will  be  expelled  in  time,  and  then  an  enema  may  be 
given  to  thoroughly  empty  the  colon  and  rectum. 

A  clamp  is  now  inserted  through  the  anus,  one  blade  of  which  is 
introduced  through  the  button-hole  {A,  Fig.  143),  and  the  other 
blade  through  the  stricture-opening  (D,  Fig.  143),  and  firmly  clamped 
upon  the  septum  {A  to  B,  Fig.  143).  Each  succeeding  day  the  han- 
dles of  the  clamp  are  pressed  together  one  or  two  notches  until  the 
septum  is  completely  severed,  usually  by  the  third  day.  The  calibre 
of  the  rectum  will  now  be  increased  by  the  addition  of  the  extra 
channel  as  represented  {E  to  D,  Fig.  143). 

In  cases  where  the  rectal  stricture  extends  down  almost  to  the 
internal  sphincter,  the  operation  may  be  done  by  the  sacral  method. 


NON-MALIGISTANT   STRICTURE   OF   THE   RECTUM. 


273 


Where  the  sigmoid  mesentery  is  normal  in  length,  strictures  of 
the  sigmoid  may  be  treated  by  the  same  operation  as  for  stricture 
of  the  rectum. 

Stricture  of  the  Anus. 

In  stricture  involving  the  anus  only  and  extending  not  more 
than  an  inch  into  the  rectum  the  following  operation  may  be  per- 
formed. 

The  anus  is  divided  in  the  median  line  front  and  back,  Fig.  146. 


Fig.  146. 
First  Step  in  Operation  for  Stricture  at  Anus. 


The  mucous  membrane  is  dissected  up  in  front  and  behind  until  it 
can  be  drawn  into  the  outer  angles  of  the  skin  incisions,  Fig.  147. 


Fig.  147. 
Second  Step  in  Operation  for  Stricture  at  Anus. 


The  mucous  membrane  is  then  sutured  to  the  free  edges  of  the 

w 
18 


skin  incision  with  the  result  shown  in  Fig,  148 


274 


SURGEEY  OF  THE  EECTUM  AND  PELVIS. 


This  operation  is  particularly  adapted  to  strictures  of  slight  ex- 
tent, due  to  contraction  of  the  skin  of  the  anus — such  as  might  be 


^ 


Fig.  148. 
Completion  of  Operation  for  Stricture  at  Anus. 


caused  by  burns  or  by  too  free  removal  of  skin  in  the  operations  for 
hemorrhoids.  It  is  successful  in  that  it  draws  down  healthy  mucous 
membrane  to  take  the  place  of  cicatricial  tissue. 

In  another  class  of  cases  the  injury  to  the  lower  part  of  the  rec- 


Fig.  149. 
First  Step  in   Operation  for   Stricture   at   Anal  Mucous  Membrane. 

tum  may  have  been  so  extensive  that  to  dissect  up  and  draw  down 
sufficient  mucous  membrane  to  transplant  into  the  anus  would  be  at- 
tended by  danger.     These  are  cases  in  which  more  or  less  extensive 


NON-MALIGNANT   STRICTCJEE   OF   THE   RECTUM. 


275 


periproctitis  has  resulted  in  contraction.  In  them  the  skin  around 
the  anus  must  be  drawn  into  the  orifice  to  supplement  the  mucous 
membrane,  instead  of  mce  versa,  and  for  this  Dieffenbach  has  recom- 
mended the  following  operation  : 

An  incision  is  made  front  and  back,  as  in  the  former  case,  but  ex- 
tending only  as  far  outward  as  the  margin  of  the  anus,  and  this  is 
joined  by  a  semilunar  incision  anteriorly  and  posteriorly,  as  shown 
in  Fig.  149. 


Fig.   150. 
Second  Step  in  Operation  for  Stricture  at  Anal  Mucous  Membrane. 

The  flaps  of  skin  included  in  the  semilunar  incisions  are  next 
carefully  dissected  up  from  the  cellular  tissue,  as  shown  in  Fig.  150, 
drawn  into  the  anal  incision,  and  sutured,  as  in  Fig.  151. 


Fig.  151. 
Third  Step  in  Operation  for   Stricture   at   Anal    Mucous  Membrane. 


CHAPTER    XYI. 


CANCER. 


In  a  general  way  it  is  undoubtedly  true  that  new  growths  in  the 
rectum,  when  benign,  increase  slowly,  tend  to  grow  away  from  the 
wall  of  the  bowel,  to  form  pedicles  for  themselves  and  to  project  into 
the  calibre  of  the  canal,  to  remain  movable,  and  not  to  involve  sur- 
rounding parts  ;  while  with  cancerous  formations  the  tendency  is 
just  the  opposite.  In  this  way  tlie  diagnosis  between  a  benign  polyp 
and  a  cancerous  infiltration  of  the  wall  of  the  rectum  is  .generally 
easy. 

But  there  is  a  class  of  tumors  which  occupies  the  border-line  be- 
tween the  benign  and  the  malignant,  in  which  the  diagnosis,  either 
clinically  or  with  the  microscope,  may  be  difficult  and  even  impos- 
sible. In  fact,  recent  careful  study  of  these  rectal  tumors  goes  far  to 
break  down  the  lines  between  the  varieties  which  are  usually  drawn  ; 
and  Cripps,  who  has  done  such  careful  and  valuable  work  in  this  de- 
partment, is  inclined  to  group  nearly  all  of  them  under  the  single 
head  of  adenoma,  holding  that  all  are  primarily  affections  of  the 
glandular  element.  The  true  nature  of  the  growths  may  perhaps 
best  be  gleaned  from  a  comparison  of  Fig.  152  with  Fig.  119,  the 
latter  being  a  benign  polypus,  and  the  former  a  malignant  growth, 
but  both  being  adenomata. 

According  to  Cripps,  the  names  malignant,  semi-malignant,  and 
simple  adenoid  will  cover  both  the  benign  and  cancerous  growths  of 
this  part  of  the  body,  except  possibly  the  form  of  colloid.  Generally, 
but  not  always,  it  is  possible  to  distinguish  between  them  both  clini- 
cally and  microscopically. 

After  speaking  of  the  innocent  growth,  which  is  soft,  has  a  fairly 


CANCER. 


277 


marked  pedicle,  and  projects  into  the  cavity  of  the  bowel,  he  says  : 
"  In  the  more  malignant  varieties,  the  new  growth  frequently  spreads 
as  a  thin  layer  between  the  muscular  and  mucous  coats.  In  this 
form  it  often  occupies  several  square  inches  of  the  bowel,  while  its 
thickness  does  not  exceed  a  quarter  of  an  inch.  At  first  the  mucous 
membrane  lies  intact  over  such  a  layer,  but  eventually  it  gives  way 
by  ulceration.  This  ulceration  sometimes  begins  at  more  than  one 
point,  so  that  the  mucous  membrane  becomes  honeycombed,  and 
portions  of  the  subjacent  growth  may  even  sprout  through  it. 

"The  destructive  process  not  only  destroys  the  mucous  membrane 
over  the  surface  of  the  growth,  but  after  awhile  the  new  growth  is 


Fig.  153. 
Cancer  of  Rectum. 


itself  destroyed  by  ulceration.  While  destruction  is  proceeding 
toward  the  centre,  the  growth  is  advancing  toward  the  circumference. 

"  In  this  way  a  crater-like  mass  of  disease  is  produced,  the  centre 
of  which  consists  of  dense  librous  tissue  belonging  to  the  muscular 
coat  of  the  bowel,  which  appears  for  long  to  resist  the  ulcerative  pro- 
cess. The  margin  of  the  crater  consists  of  the  mucous  membrane  of 
the  bowel,  heaped  up  by  the  extending  growth  beneath  it,  tucking  it 
over  in  such  a  manner  as  to  overlap  the  healthy  membrane.  The 
border  is  at  times  so  irregular  as  to  represent  a  series  of  nodules 
rather  than  a  continuous  line." 

Stimson  has  also  made  a  careful  study  of  these  growths.  He 
says:  "If  it  is  admitted  that  cancer  of  the  rectum  is  essentially  a 
glandular  or  epithelial  affection,  one  having  its  origin  in  the  mucous 


278  SUEGERY   OF   THE   EECTUM   AiSTD   PELVIS. 

membrane,  the  borders  of  tlie  growth,  as  being  the  freshest,  most  re- 
cent portions,  must  be  examined,  as  in  carcinoma  of  otlier  organs, 
for  evidences  of  primary  changes  and  mode  of  development. 

"  These  changes  consist  of  hypertrophy  of  the  mucosa  by  hyper- 
trophy and  hyperplasia  of  its  epithelial  elements,  together  with  an 
abundant  development  of  embryonal  connective  tissue  between  the 
tubules.  They  are  the  same  as  those  found  in  a  variety  of  neoplasm 
of  recognized  benign  character  known  as  polyp  of  the  rectum,  or 
polj^poid  adenoma.  The  formation  of  a  pedunculated  growth  with  a 
tendency  to  isolation  in  the  one  case,  and  of  a  flat  growth  with  a  ten- 
dency to  spread  laterally  and  into  the  underlying  tissue  in  the  other, 
may  be  explained  partly  by  mechanical  causes  and  partly  by  the  de- 
gree of  intensity  of  the  changes  in  the  submucous  connective  tissue. 

"  If  the  primary  change  occupies  a  limited  area  upon  a  natural  fold 
of  the  mucous  membrane,  and  if  the  muscularis  mucosae  remains 
unbroken  until  the  young  embryonal  cells  produced  below  it,  in  con- 
sequence of  the  neighboring  irritation,  have  had  time  to  develop  into 
adult  fibrous  tissue,  the  natural  retraction  of  this  new  tissue  narrows 
the  base  of  the  fold,  giving  it  at  once  a  polypoid  form  and  opposing 
by  its  greater  density  a  stronger  barrier  to  the  extension  of  the  epi- 
thelial formation  in  this  direction. 

"The  pedicle  once  formed,  the  neoplasm  increases  in  the  direction 
open  to  it,  that  is,  into  the  lumen  of  the  canal  in  all  its  diameters, 
and  the  dragging  to  which  it  is  subjected  by  the  constantly  recurring 
passage  of  the  faeces  lengthens  its  pedicle  and  tends  toward  its  final 
separation. 

"  On  the  other  hand,  if  a  broader  area  is  occupied  by  the  primary 
change,  or  if  the  processes  are  more  intense  and  rapid,  the  peduncu- 
lation  is  absent  or  less  perfect,  and  the  epithelial  growths  of  the 
mucosa  break  through  immediately,  or  after  an  interval  spent  in 
overcoming  the  greater  resistance  offered  by  the  partial  peduncula- 
tion  into  the  submucous  tissue.  Once  established  in  that  region, 
the  spread  of  the  disease  is  easy,  and  its  ultimate  generalization  a 
question  only  of  time. 

"The  second  and  final  barrier  to  generalization  is  presented  by 
the  muscular  coat  of  the  intestine,  but  it  is  a  barrier  in  which  are 
many  gaps,  large  ones  along  the  lines  of   the  vessels,  and  innumer- 


CANCER. 


279 


mr 


\i 


stS 


.  %;5¥*'^-"'"'"'  ^# 


Fig.  153. 
Cancer. 


2S0  SURGEEY    OF   THE    EECTUM    AXD    PELVIS. 

able  small  ones  in  the  fine  meshes  of  connective  tissue  which  sep- 
arate the  muscular  bundles  and  are  continuous  with  the  submucous 
tissue  on  one  side  and  tlie  pararectal  tissue  on  the  other. 

"Here,  too,  the  intensit}^  of  the  process  materially  afi'ects  the 
rapidity  of  its  extension  ;  for  if  the  proliferating  connective  tissue, 
which  is  most  easily  implicated  while  it  is  in  the  formative  stage,  is 
allowed  time  to  reach  its  full  development,  to  become  fibrous,  it 
forms,  as  it  were,  a  second  line  of  defence  capable  of  offering  a  cer- 
tain resistance  after  the  first  line  has  been  carried.'' 

Of  all  the  varieties  of  true  cancer  the  one  most  frequently  met 
with  is  epithelioma,  and  this  presents  itself,  here  as  elsewhere  in  the 
body,  under  two  forms,  distinguishable  with  the  microscope  and 
clinically. 

The  first  (cancroid,  lobulated  epithelioma)  contains  the  character- 
istic onion-like  nests  of  squamous  epithelium,  and  is  the  same  form  so 
commonly  seen  in  the  lip,  though  rarel}^  about  the  anus.  It  has  its 
point  of  origin  at  the  anus,  and  not  within  the  rectum,  and  begins  as 
a  hard,  dr}^,  warty  nodule.  It  is  slow  in  progress,  covered  at  first 
with  firm  epidermis,  and  only  begins  to  ulcerate  late  in  its  course. 
It  seldom  spreads  far  up  the  rectum,  but  tends  rather  to  involve  the 
integument,  which  it  may  destroy  to  an  extent  similar  to  that  some- 
times seen  in  the  same  variety  of  disease  about  the  face.  This  form 
of  disease  is  rare. 

In  the  other  variety  (cylindrical  ejDithelioma)  the  cells  are  colum- 
nar, and  the  growth  resembles,  in  minute  structure,  the  mucous  mem- 
brane from  which  it  springs.  This  variety,  on  the  contrary,  chooses 
the  rectum  proper  for  its  development,  and  is  found  above  the  in- 
ternal sphincter.  It  is  easily  distinguished  from  the  former,  but  not 
so  easily  from  a  scirrhus  which  has  begun  to  ulcerate.  It  is  softer 
than  the  other,  more  vascular,  and  therefore  more  prone  to  bleed 
and  undergo  extensive  degeneration  and  ulceration,  and  it  rapidly 
infiltrates  surrounding  tissues. 

Early  in  its  course  it  is  movable  on  the  subjacent  tissues,  but  it  is 
seldom  seen  by  the  surgeon  at  this  stage.  At  a  later  period  it  pre- 
sents itself  as  a  soft,  friable  mass  seated  on  a  hard,  infiltrated  base  ; 
ulcerated  in  spots,  the  edges  of  the  ulcers  being  hard  and  raised. 

Next  to  epithelioma,  scirrJius,  or  hard  cancer,  is  the  variety  most 


CANCER.  281 

frequently  met  with  in  the  rectum.  It  arises,  not,  like  epithelioma, 
in  the  mucous  membrane,  but  in  the  submucous  connective  tissue  ; 
therefore,  in  the  early  stages  of  its  growth  the  membrane  is  found 
normal  and  movable  over  the  hard  mass  beneath.  When  cut  into  it 
shows  the  characteristic  raw-potato-like  hardness  of  scirrhus,  and 
there  is  no  distinct  line  of  demarcation  between  it  and  the  adjacent 
tissues.  From  the  original  tumor  are  often  seen,  and  sometimes  felt, 
hard,  fibrous  bands  spreading  out  in  various  directions,  generally 
longitudinally,  in  the  bowel — the  processes  or  claws  from  which  can- 
cer takes  its  name. 

These  tumors  may  soften  down  in  parts  and  slough  or  ulcerate 
away.  When  ulceration  has  begun,  a  cavity  with  an  irregular  out- 
line is  formed  in  the  midst  of  the  hard  cancer  tissue,  from  w^iich 
issues  a  fetid  discharge  mixed  with  more  or  less  blood  and  pus. 
Although  a  large  part  of  the  growth  may  die  in  this  way  and  be  dis- 
charged, the  steady  increase  in  the  disease  is  not  checked.  Indeed, 
the  growth  often  seems  to  be  most  rapid  in  the  bed  of  the  part  which 
has  been  destroyed. 

Cancer  of  the  rectum,  like  cancer  elsewhere  in  the  body,  generally 
occurs  in  middle  life  or  old  age.  There  are,  however,  some  interest- 
ing exceptions  to  this  rule,  cases  having  been  recorded  from  the  age 
of  six  years  upwards.  After  the  age  of  twenty  the  cases  increase  rap- 
idly in  number. 

With  regard  to  the  relative  frequency  in  the  sexes,  different 
statements  will  be  found  in  the  works  of  different  writers,  according 
to  the  experience  each  has  had,  and  considerable  reasoning  has 
been  indulged  in  to  explain  why  the  disease  should  be  more  common 
in  the  one  sex  than  in  the  other.  In  a  collection  of  one  hundred  and 
fifty  cases  of  my  own,  I  have  found  the  disease  about  equally  divided 
between  the  two  sexes. 

The  symptoms  of  cancer  of  the  rectum  may  be  classified  as  follows  : 
pain  ;  those  due  to  contraction,  to  ulceration,  to  Invasion  of  neigh- 
boring parts  ;  and,  lastlj^,  the  generalization  of  the  disease  and  the 
cachexia. 

A  cancer  of  the  rectum  often  begins  so  insidiously  that  its  exist- 
ence is  not  suspected  by  the  patient  till  it  has  made  irreparable  prog- 
ress.    This  will  be  the  case  particularly  when  the  disease  is  well  up 


282  SUEGEEY   OF   THE   KECTUM   AND   PELVIS. 

in  the  bowel  beyond  the  reach  of  the  sphincters.  On  the  other  hand, 
the  disease  is  usually  attended  with  great  pain,  and  the  character  of 
the  pain  may  be  of  great  assistance  in  diagnosis. 

Attention  has  been  called  to  the  point  in  diagnosis  that  the 
existence  of  pain  or  cramp  in  the  lower  extremity  in  cancer  of  the 
rectum  is  a  bad  sign,  suggesting  a  direct  encroachment  upon  some  of 
the  neighboring  nerves,  either  by  implication  and  pressure  of  the 
glands,  or  by  direct  extension  of  the  original  disease. 

In  the  later  stages  of  cancer  the  pain  is  often  the  most  important 
symptom  to  be  met  by  treatment.  It  may  then  be  due  to  the  ir- 
ritation of  faeces  upon  an  ulcerated  surface,  to  the  involvement 
of  the  anus  in  the  ulceration,  or  to  direct  pressure  on  adjacent 
parts,  and  each  of  these  is  to  be  met  by  a  different  and  appropriate 
treatment. 

The  symptoms  directlj^  referable  to  contraction  of  the  bowel  are 
often  slight,  and  differ  in  no  way  from  those  caused  by  the  fibrous 
stricture  of  the  same  part.  It  is  often  astonishing  to  the  surgeon  to 
meet  with  an  advanced  case  of  scirrhus  in  which  the  calibre  of  the 
bowel  is  so  nearly  occluded  as  scarcely  to  permit  the  passage  of  the 
end  of  the  finger,  and  yet  in  which  the  patient  has  never  had  sulfi- 
cient  uneasiness  to  call  for  a  direct  rectal  examination. 

The  hemorrhage  from  an  ulcerated  rectum  in  cancerous  disease  is 
seldom  profuse  enough  to  be  dangerous,  though  by  frequent  repeti- 
tion it  may  become  an  important  factor  in  the  ultimately  fatal 
result.  Only  once  in  my  experience  have  I  seen  cancer  of  the  rectum 
manifest  itself  by  profuse  and  nearly  fatal  hemorrhage  as  a  very 
early  symptom. 

Above  the  contraction  there  may  develop  an  ulceration  which  is 
not  to  be  confounded  with  the  breaking  down  of  the  cancer  itself. 
(Fig.  154.)  When  the  cancer  itself  once  begins  to  break  down  and 
ulcerate,  its  extension  is  limited  by  no  tissue  of  the  body.  The  blad- 
der may  be  opened  and  a  permanent  fistula  result,  in  which  case  the 
passage  is  generally  from  that  viscus  into  the  rectum  ;  but  the  oppo- 
site may  be  the  case— and  the  pain  caused  by  the  entrance  of  faeces 
into  the  bladder  and  their  discharge  through  the  urethra  is  one  of  the 
best  of  all  the  indications  for  colostomy.  The  prostate  and  seminal 
vesicles  in  the  male  and  the  recto-vaginal  septum  in  the  female  may 


CANCER. 


283 


Fig.  154. 
Cancer  of  the  Rectum,  showing  Dilatation  above  the  Stricture. 


^84  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

each  be  destroyed  ;  in  fact,  any  part  near  the  disease  may  be  impli- 
cated. 

There  are  two  sets  of  lymphatics  which  may  be  involved  in  ma- 
lignant disease  of  the  rectum,  one  coming  from  the  anus  and  going  to 
the  glands  in  the  groin  ;  and  one  coming  from  tlie  rectum  proper  and 
going  to  the  glands  in  the  hollow  of  the  sacrum  and  lumbar  region. 
The  proper  place,  therefore,  to  feel  for  glandular  involvement  in  the 
disease  within  the  sphincter  is  along  the  spine,  deep  in  the  pelvis— a 
simple  point  which  may  decide  the  surgeon  as  to  the  proper  form  of 
operative  interference. 

From  what  has  been  said  it  is  evident  that  there  is  little  in  the 
history  which  the  patient  will  give  of  cancer  of  the  rectum  to  distin- 
guish it  from  ulceration  and  stricture  of  any  other  variety,  except 
that  when  a  patient  of  middle  age  complains  of  bloody  and  mucous 
discharges  and  difficulty  in  defecation,  which  have  come  on  within  a 
short  time,  and  is  at  the  same  time  losing  flesh  and  strength,  the  ex- 
aminer's suspicions  should  be  aroused. 

The  diagnosis  must  rest  chiefly  upon  a  physical  examination, 
however,  and  to  make  such  an  examination  thoroughly,  and  yet 
safely,  requires  great  care  and  gentleness  ;  and  to  properly  interpret 
the  conditions  which  may  be  found,  no  little  experience  and  knowl- 
edge. 

In  the  majority  of  cases  the  diagnosis  may  be  made  by  the  history 
and  by  physical  examination  with  the  finger  alone.  Cancer  in  this 
locality  is  a  disease  of  rapid  growth,  and  when  a  patient  says  that 
stricture  has  existed  any  considerable  number  of  years  the  idea  of 
malignancy  may  be  abandoned.  Something  also  may  be  learned 
from  the  general  appearance  of  the  patient,  but  most  of  all  from  the 
digital  examination. 

When  the  disease  is  seen  in  its  earlier  stages,  the  hard,  more  or 
less  distinctly  circumscribed  new  growth  which  has  infiltrated  the 
4 wall  of  the  bowel  is  diagnostic.  The  great  difficulty  is  to  distinguish 
between  an  advanced  case  where  the  rectum  is  partially  occluded  by 
hard  masses  of  disease,  and  an  old  case  of  stricture  and  ulceration 
which  is  not  malignant.  This  may  sometimes  be  impossible  except 
by  the  microscope,  and  inflammatory  disease  of  the  rectum  is  not  in- 
frequently mistaken  for  cancer. 


CANCER.  285 

When  a  soft,  friable  mass  of  epithelioma  is  found  seated  on  a 
hard,  infiltrated  base  which  is  ulcerated  in  spots,  the  edges  of  the 
ulcers  being  hard  and  raised,  the  diagnosis  is  also  easy. 

Cancerous  stricture  of  the  sigmoid  flexure,  or  of  the  upper  part 
of  the  rectum  above  the  limit  of  digital  examination,  is  the  most 
difficult  to  diagnosticate,  and  may  sometimes  escape  the  most  thor- 
ough search.  It  may  also  end  fatally  from  acute  intestinal  obstruc- 
tion before  it  has  caused  sufficient  symptoms  to  make  its  existence 
suspected ;  for  this  part  of  the  canal  is  very  movable,  easily  forced 
out  of  its  natural  relations,  and  subject  to  complete  occlusion  by  an 
amount  of  new  growth  which  lower  down  in  the  rectum  would  cause 
only  slight  difficulty  in  defecation,  as  already  explained. 

I  know  of  no  other  means  of  diagnosis  in  these  cases  than  those 
already  described  under  non-malignant  stricture  ;  but  the  experienced 
examiner,  if  he  suspect  malignancy,  is  much  more  cautious  than 
with  non-malignant  disease  in  the  use  of  the  bougie,  for  he  knows 
how  easily  a  cancerous  stricture  will  tear  and  cause  sudden  death. 

In  cases  where  the  condition  is  more  complicated  and  where  sec- 
ondary deposits — in  the  liver,  for  example — have  begun  to  do  their 
fatal  work  before  actual  obstruction  has  begun,  the  symptoms  of 
stricture  may  all  be  obscured  by  the  presence  of  others  which  shall 
more  readily  attract  the  eye.  In  one  case  I  had  made  the  diagnosis 
of  cancer  of  the  liver  with  ascites  and  great  intestinal  disturbance, 
some  time  before  my  attention  was  called  to  the  rectum,  and  it  be- 
came evident  by  examination  that  the  affection  of  the  liver  was 
secondary  to  malignant  disease  high  up  in  the  rectum,  which  was 
also  gradually  involving  the  pelvic  viscera. 

The  termination  of  the  disease  is  more  often  by  a  gradual  exhaus- 
tion of  the  patient's  powers  than  by  complete  obstruction,  although 
it  may  come  in  either  way.  The  loss  of  rest  which  comes  from  the 
continual  tenesmus  and  the  pain  are  the  most  active  elements  in 
shortening  life. 

Treatment. 

The  treatment  is  general  and  local.  In  the  way  of  general  treat- 
ment nothing  can  be  added  to  what  has  already  been  said  under  non- 
malignant  stricture,  except  perhaps  a  word  of  advice  against  the  too 


286  SUEGEEY   OF   THE   KECTUM   AND   PELVIS. 

early  and  free  use  of  opium.  IS^o  matter  what  line  of  treatment  be 
followed  or  what  operation  may  be  done,  in  the  end  opium  is  apt  to 
prove  the  sufferer's  best  and  only  friend.  Nobody  has  less  scruple 
against  getting  the  full  benefit  of  it  than  I,  but  unfortunately,  when 
used  freely  in  the  first  of  the  disease,  it  loses  its  effect  when  most 
needed,  and  to  the  pains  of  cancer  are  often  added  those  of  the 
chronic  opium  habit.  Therefore  I  begin  its  use  reluctantly  in  every 
case,  holding  off  as  long  as  seems  wise,  and  then  try  carefully  to  reg- 
ulate the  daily  dose. 

In  the  surgical  treatment  of  cancer  it  must  be  plainly  understood 
that  none  of  the  means  mentioned  under  non-malignant  stricture — 
neither  cautery,  division,  divulsion,  dilatation,  nor  electrolysis — have 
any  place.  The  resources  at  our  command  are  only  two — extirpation 
and  colostomy.  One  of  these  should  be  performed  as  soon  as  the 
case  comes  under  observation,  and  all  other  interference  with  the 
growth  abstained  from. 

I  know  of  nothing  better  calculated  to  fill  a  surgeon  with  disgust 
than  the  story  of  some  poor  sufferer  that  somebody  has  been  using 
a  speculum  two  or  three  times  a  week  and  applying  caustics  or  elec- 
tricity to  his  cancerous  rectum.  Not  only  is  this  kind  of  local  treat- 
ment harmful  by  increasing  the  rapidity  of  the  growth,  but  it  is  also 
much  more  dangerous  than  one  without  experience  would  believe. 
It  has  long  been  excellent  surgery  to  either  remove  a  cancer  com- 
pletely or  else  to  let  it  alone. 

Nothing  is  ever  gained,  and  years  of  useful  life  may  be  lost,  by 
postponing  till  a  more  convenient  season  an  operation  for  cancer  of 
the  rectum,  whether  it  be  extirpation  or  colostomy.  If  colostomy  is 
indicated  at  all,  the  time  to  perform  it  is  immediately  after  it  has 
been  decided  not  to  do  excision,  not  after  intestinal  obstruction  has 
set  in,  or  after  the  sufferer  has  reached  the  closing  days  of  lingering 
disease. 

The  choice  between  extirpation  and  colostomy  in  any  case  may 
be  easy  or  may  be  very  difficult.  In  some  cases  extirpation  is 
manifestly  not  to  be  thought  of  and  immediate  colostomy  may  be 
done.  In  others,  extirpation  holds  out  so  good  a  chance  of  prolonging 
life,  and  possibly  even  of  effecting  a  radical  cure,  that  it  is  plainly 
indicated.    Between  these  two  classes  there  is  a  large  group  of  cases 


CANCER.  287 

where  the  indications  for  treatment  are  not  as  plain  as  they  should 
be. 

The  late  Dr.  Van  Buren,  some  years  ago,  tried  to  lay  down  the 
rules  which  should  guide  us  in  selecting  cases  for  excision.  They 
were  very  simple.  The  growth  must  be  distinctly  circumscribed, 
movable  on  subjacent  tissues,  and  within  easy  reach  by  an  incision 
through  the  perineum.  Since  his  time  Kraske  has  given  us  an 
entirely  new  operation.  By  an  incision  over  the  sacrum  he  proved 
the  possibility  of  resecting  portions  of  the  rectum  too  high  to  be 
reached  by  an  incision  from  the  perineum,  and  too  low  to  be  reached 
by  laparotomy. 

By  a  combination  of  Kraske' s  operation  and  the  old  one  by  peri- 
neal incision,  it  has  therefore  become  possible  to  either  resect  long 
pieces  of  the  rectum,  or  to  amputate  long  portions  which  would  have 
been  inoperable,  according  to  Van  Buren's  rules,  on  account  of  their 
distance  from  the  perineum.  The  advance  must  not  be  overesti- 
mated. We  can  now  amputate  six  inches  of  rectum  instead  of  three, 
or  we  can  resect  a  circular  carcinoma  at  a  point  six  inches  from  the 
anus  ;  but  to  do  any  good  we  must  still  confine  our  operations,  as 
Van  Buren  insisted,  to  cancer  of  the  gut,  and  not  of  the  gut  and  sur- 
rounding tissues,  and  to  an  early  stage  of  cancer  at  that. 

In  trying  to  reach  safe  conclusions  on  this  subject  it  is  necessary 
to  be  very  accurate.  There  are  many  cases  in  which  extirpation 
should  certainly  not  be  performed,  and  there  are  some  which  just  as 
certainly  should  not  be  subjected  to  colostomy,  at  least  until  after 
excision  has  been  tried.  The  former  are  those  of  extensive  disease 
involving  not  only  the  rectum  but  the  adjacent  tissues,  and  in  this 
class  I  personally  include  many  upon  which  others  would  operate. 

For  my  own  part,  I  have  finished  trying  to  dissect  a  cancerous 
rectum  away  from  the  base  of  the  bladder  when  it  would  almost 
require  a  microscope  to  decide  whether  all  of  the  disease  had  been 
removed  or  not,  for  in  such  cases  I  expect  an  immediate  recurrence, 
and  often  before  the  incision  has  healed.  I  have  also  finished  re- 
moving the  deep  urethra,  prostate,  and  seminal  vesicles  to  make 
sure  without  a  microscope  that  all  of  the  cancer  is  removed,  for  in 
those  cases  I  expect  either  death  from  the  operation  or  immediate 
recurrence. 


288  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

The  cases  in  which  extirpation  should  be  done  with  a  hope  of  cure 
are  tliose  of  epithelioma  low  down  in  the  rectum,  and  more  especially 
those  which  begin  at  the  anus  and  secondarily  involve  the  rectum. 
These  are  the  ones  which  are  curable  by  excision,  or,  if  not  curable, 
those  in  which  recurrence  is  longest  delayed. 

But  besides  these  there  is  a  class  of  cases  in  which  the  rule  for 
treatment  is  still  to  be  considered.  These  are  the  cases  of  annular 
scirrhus  of  the  rectal  pouch,  or  even  of  the  upper  rectum,  which  are 
manifestly  removable  without  more  than  the  average  risk.  In  these 
we  must  determine  which  operation  will  give  the  greater  length  of 
life,  extirpation  or  colostomy. 

In  extirpation  we  do  a  capital  surgical  operation,  for  the  hope  of 
cure  in  part,  and  failing  this,  for  the  certainty  of  palliation  of  suffer- 
ing and  the  probable  prolonging  of  life.  In  colostomy  we  do  an 
operation  with  scarce  any  risk  and  with  no  hope  of  cure.  But  we 
invariably  prolong  life,  and  sometimes  for  several  years  ;  we  relieve 
pain  ;  we  secure  the  greatest  possible  length  of  days  next  to  a  cure, 
and  we  lead  the  sufferer  gently  down  to  the  grave. 

In  substituting  an  artificial  anus  in  the  groin  for  the  natural  one, 
it  must  be  remembered  that  patients  with  cancer  of  the  rectum,  as  a 
rule,  have  very  little  sphincteric  power  or  ability  to  retain  fecal 
matter.  Either  there  is  a  constant  discharge  which  necessitates  the 
wearing  of  a  napkin  at  all  times,  or  there  is  a  constant  uneasiness  and 
fear  of  accident  which  keeps  them  in  close  proximity  to  the  commode 
day  and  night.  To  them  one  daily  solid  evacuation,  even  if  it  does 
escape  from  the  groin,  is  a  great  advantage,  and  the  choice  is  not 
between  fecal  control  by  the  anus  and  incontinence  in  the  groin,  but 
between  one  or  two  daily  solid  evacuations  from  the  groin  and  a  con- 
stant leakage  of  bloody  mucus  and  faeces  from  the  natural  anus. 

The  question  of  the  immediate  risk  of  excision  will  have  consider- 
able weight  in  determining  the  choice  of  both  surgeon  and  patient. 
This  is  now  reduced  to  about  fifteen  per  cent,  in  the  hands  of  skilled 
and  experienced  operators. 

Regarding  the  question  of  radical  cure,  we  find  difficulty  in 
establishing  exact  data,  and  have  to  take  into  consideration  the  repu- 
tation of  the  reporter.  We  find,  however,  a  constant  improvement  in 
this  regard,  depending  probably  on  the  fact  of  earlier  operation. 


CANCER.  289 

The  operation  is  not  followed  by  any  after-consequences  which 
are  of  sufficient  gravity  to  coiitra-indicaLe  its  performance. 

In  a  small  proportion  of  cases  there  will  be  complete  incontinence; 
in  a  greater  number  there  will  be  partial  control  over  the  evacuations  ; 
in  a  majority  the  control  will  be  sufficiently  complete  to  prevent  the 
occurrence  of  any  annoying  accident ;  in  some  there  will  be  some  cica- 
tricial stenosis,  and  a  fecal  fistula  is  apt  to  follow  the  high  operation. 

Dr.  McCosh,  in  a  paper  read  before  the  New  York  Surgical 
Society,  has  carried  the  statistics  down  to  a  recent  date  and  essenti- 
ally changed  them.  In  four  hundred  and  thirty-nine  operations  there 
were  eighty-four  deaths,  or  19.1  per  cent.  ;  and  in  three  hundred  and 
seventy-five  operations  there  were  thirty-two  cases,  or  about  ten  per 
cent.,  showing  no  recurrence  in  four  years.  Unfortunately,  there  is 
no  description  of  the  location,  character,  or  extent  of  the  disease  in 
these  favorable  cases. 

Regarding  the  best  way  of  performing  the  operation,  the  surgeon 
lias  his  choice  of  several.  Almost  every  surgeon  whose  name  is  promi- 
nently associated  with  the  operation  has  had  his  own  favorite  way 
of  performing  it,  but  all  of  these  may  now  be  grouped  under  two 
general  heads  :  the  operation  through  the  perineum,  and  Kraske's 
operation,  or  excision  by  an  incision  at  the  side  of  the  sacrum. 

The  old  operation  by  the  perineum  has  many  objections.  The 
incision  is  too  small  for  the  work  attempted  ;  and  though  the  growth 
may  be  removed  it  is  only  at  the  expense  of  great  loss  of  blood,  which 
is  beyond  the  surgeon's  control  merely  from  lack  of  space  in  which  to 
wrork.  The  operation  is  only  applicable  to  growths  near  the  anus 
which  are  to  be  amputated.  Resection  and  suture  rendered  possible 
by  the  dorsal  incision  are  impossible  by  the  perineal. 

Certainly  the  quickest  operation,  though  often  a  very  bloody  one, 
is  the  one  figured  in  the  three  following  cuts. 

The  instruments  necessary  are  : 

Knife. 

Strong  straight  scissors. 

Artery  forceps. 

Curved  needles. 

Needle-holder. 

Catgut. 

Large  sponges. 

19 


290 


SURGERY   OF   THE   RECTUM   AND   PELVIS. 


The  patient  being  held  in  the  lithotomy  position  by  Clover's 
crutch,  the  index  finger  of  the  left  hand  is  introduced  into  the  rec- 
tum as  high  as  the  limit  of  the  disease,  and  the  knife  is  entered 


Pjg.  155. 
First  Step  in  Excision  of  Rectum. 


through  the  skin  outside  of  the  anus  and  carried  upward  in  the  cel- 
lular tissue  behind  the  gut  as  far  as  the  finger  in  the  rectum  shows  it 
to  be  necessary. 


Fig.  156. 
Second  Step  in  Excision  by  the  Perineum. 


A  deep  dorsal  cut  is  then  made  down  to  the  tip  of  the  coccyx, 
and  past  this  point  if  necessary  for  room.  Next  the  rectum  is 
divided  circularly  between  the  lower  limit   of  the  growth  and  the 


CANCER. 


291 


external  sphincter,  if  possible.  Tliis  incision  should  go  deeply  into 
the  cellular  tissues,  and  is  ended  by  dividing  the  external  sphincter 
posteriorly.     In  this  way  the  sphincter  is  left  in  the  skin  flaps. 

The  diseased  rectum  is  still  to  be  dissected  out  as  a  cylinder,  and 
this  should  be  done  boldly  and  rapidly  with  knife  and  scissors  till 
the  enucleation  has  proceeded  to  a  level  at  least  half  an  inch  above 
the  disease.  The  wound  should  be  packed  with  sponges  as  fast  as 
the  cutting  proceeds,  and  when  the  gut  has  been  entirely  freed  from 
its  attachments,  the  sponges  may  be  removed  and  the  vessels  at- 
tended to.     The  bleeding  will  be  excessive  if  the  operator  stops  to 


Fig.  157. 
Third  Step  in  Excision  by  the  Perineum. 


tie  each  vessel  as  it  is  cut,  and  the  secret  of  the  operation  is  to  work 
as  rapidly  as  possible  and  control  the  bleeding  by  pressure.  After 
the  bleeding  has  been  stopped  and  the  sponges  removed,  the  rectum 
should  be  amputated  with  the  ecraseur  or  knife,  care  being  taken  not 
to  lose  the  upper  end,  but  to  keep  it  in  sight  with  a  volsellum  till  it 
has  been  attached  by  a  few  stitches  to  the  skin  of  the  anus. 

The  rectum  should  not  be  drawn  down  too  tightly  by  sutures, 
lest  they  tear  out  in  the  first  day.  The  wound  should  be  fully 
drained  and  stuffed  with  iodoform  gauze,  and  no  attempt  should  be 
made  to  get  union  by  first  intention. 

I  have  performed  this  operation  with  very  satisfactory  results  in 


292  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

cases  where,  because  of  the  involvement  of  the  anus,  the  circular  in- 
cision was  made  through  the  skin  far  out  in  each  fossa. 

The  objections  to  this  operation  are  apparent  from  a  mere  descrip- 
tion, and  much  more  so  in  its  actual  performance.  If  it  be  done 
slowly  and  carefully  it  takes  a  long  time,  mostly  spent  in  tying  ves- 
sels, and  if  done  rapidly  to  avoid  hemorrhage  it  is  more  or  less  of  a 
blihd  plunge  into  the  pelvis  without  any  of  the  elements  of  preci- 
sion which  are  always  desirable  in  any  surgical  work. 

Vaginal  Incision. 

The  facility  with  which  the  rectum  may  be  reached  through  the 
vagina  has  been  pointed  out  by  Rehn  and  Campenom.  The  posterior 
vaginal  wall  may  be  divided  by  a  median  longitudinal  incision  extend- 
ing outward  and  downward  through  the  perineum  to  the  margin  of 
the  sphincter.  The  dissection  of  the  rectum  from  its  bed  may  be  done 
almost  entirel}^  with  the  handle  of  the  scalpel.  After  the  diseased 
portion  has  been  sufficiently  liberated  the  gut  may  be  closed  with  a 
ligature  both  above  and  below  in  resection,  or  above,  in  amputation, 
and  the  growth  removed.  After  suture  of  the  ends  in  resection,  or 
fixation  of  the  stump  to  the  perineum  in  amputation,  the  vaginal  in- 
cision may  be  closed.  This  incision  allows  very  free  entrance  to  the 
peritonal  cavity  also,  as  is  shown  in  vaginal  coeliotomy. 


CHAPTER  XYIL 

KRASKE'S   EXCISION  OF   THE   RECTUM. 

Under  the  general  name  of  Kraske's  operation  are  included  all  of 
the  modifications  of  the  dorsal  incision.  These  have  been  many,  each 
of  them  possessing  certain  advantages  perhaps,  but  the  guiding 
principle  in  them  all  is  the  attack  upon  the  disease  from  behind. 

The  instruments  necessary  are  : 

A  strong  scalpel. 

One  dozen  catch  forceps. 

Periosteal  elevator. 

Strong  straight  bone  forceps. 

Catgut  (fine  and  medium). 

Fine  black  silk. 

Straight  needles  for  intestine. 

Large  and  medium  curved  Hagedorn  needles. 

Needle-holder. 

Sponge-holders. 

Two  intestinal  clamps  (Fig.  158). 


„i,U/,llimiu„.„„:.„„lli„..^ „l,„l,uil:lii} 


J3l,„    G  ,.  EBMO..L.P  rS...  V, ,J 


Fig.  158. 
Intestinal    Clamp. 


At  least  four  days  should  be  allowed  in  which  to  prepare  a  pa- 
tient for  extirpation  of  the  rectum,  in  order  to  have  the  bowel  as 


294  SURGEKY   OF   THE   RECTUM   AND   PELVIS. 

empty  as  possible  at  the  time,  and  to  postpone  as  long  as  possible 
the  first  fecal  evacuation  afterward. 

On  the  first  evening  three  compound  cathartic  pills  should  be 
given,  and  these  should  be  repeated  on  the  second.  The  day  before 
operating  the  diet  should  be  exclusively  milk  and  beef-tea,  prefera- 
bly^ the  latter,  and,  on  the  evening  before,  a  dose  of  bismuth  and 
morphine  should  be  given.  This  should  be  repeated  a  few  hours 
before  the  operation. 

No  preliminary  preparation  of  the  field  of  operation  is  necessary, 
but  when  the  patient  is  under  ether  great  care  should  be  devoted  to 
this  point. 

AYith  the  patient  in  the  lithotomy  position  the  perineum  is  first 
shaved  and  the  cavity  of  the  rectum  thoroughly  cleansed  as  high  up 
as  possible.  This  is  done  through  a  speculum,  at  first  by  prolonged 
irrigation  with  bichloride  solution  (1  to  500)  and  then  by  carefully 
wiping  the  canal  with  wads  of  iodoform  gauze  on  the  end  of  long 
forceps.  This  is  necessary,  because  it  is  often  of  the  greatest  help  to 
be  able  to  introduce  the  finger  into  the  rectum  during  the  operation, 
because  the  gut  may  be  lacerated  in  trying  to  remove  it,  and  because 
in  every  case  it  must  be  cut  across  before  it  is  removed.  In  doing 
either  of  these  three  things  the  whole  wound  is  apt  to  become  in- 
fected unless  the  most  scrupulous  care  is  observed,  and  the  object  of 
the  preliminary  disinfection  of  the  calibre  of  the  gut  is  to  reduce  this 
risk  as  much  as  possible. 

The  form  of  disinfection  described  may  not  be  theoretically  or 
practically  perfect,  but  exactly  in  proportion  to  its  thoroughness, 
and  to  the  care  with  which  the  wound  is  kept  clean  during  every 
stage  of  the  operation,  will  be  the  mortality. 

A  small  tampon  of  iodoform  gauze  may  be  left  in  the  rectum, 
but  too  great  a  mass  distends  the  canal,  obscures  palpation  of  the 
diseased  part  from  the  incision,  and  distorts  the  normal  relation  of 
the  parts  during  the  operation. 

The  patient  is  next  turned  on  the  face,  or  practically  so,  and  the 
whole  site  of  the  operation  scrubbed  and  disinfected.  Soap  and 
brush  well  applied,  with  subsequent  washing  with  bichloride,  and  a 
final  wash  with  ether  will  be  found  efficient. 

The  incision  should  be  chiefiy  in  the  groove  between  the  nates, 


keaske's  excision  of  the  rectum. 


295 


and  need  be  carried  to  the  left  of  the  median  line  only  at  its  upper 
limit.  It  should  reach  from  opposite  the  promontory  of  the  sacrum 
to  the  anus,  and  the  knife  should  be  carried  directly  down  to  bone 
at  once.  Flaps  should  be  turned  to  left  and  right  by  a  few  strokes 
of  the  knife  hugging  the  bone  ;  the  flap  on  the  right  should  lay  bare 
that  side  of  the  sacrum,  that  on  the  left  must  be  carried  beyond  the 
edge  of  the  bone  in  order  to  expose  the  ligaments  connecting  it  with 
the  rest  of  the  pelvis,  and  these  should  be  divided. 

A  periosteal  elevator  is  next  passed  under  the  sacrum  from  left 


Pig.  159. 

a  d — Bardenheuer's  Incision. 
a  c — Hochenegg's  Incision. 
a  b  c — Kraske's  Incision. 


to  right  (the  operator  stands  on  the  left)  at  the  level  of  the  incision 
to  be  made  across  that  bone,  and  is  worked  down  to  the  tip  of  tlie 
coccyx,  so  as  to  separate  all  the  soft  tissues  from  the  hollow  of  the 
sacrum.  In  this  way  the  sacra  media  artery  and  the  plexus  of  veins 
are  lifted  away  from  the  bone,  and  troublesome  bleeding  during  the 
rest  of  the  operation  may  be  avoided. 

When  the  periosteal  elevator  has  been  removed  one  blade  of  a 
strong  straight  bone  forceps  is  slipped  under  the  sacrum  in  its  place 
and  the  bone  is  divided  transversely,  the  piece  cut  off  being  imme- 
diately dissected  out.  (Fig.  159)  Usually  this  triangular  piece  of 
bone  should  consist  of  the  last  two  sacral  vertebrae  and  the  coccyx. 


296 


SURGERY   OF   THE   RECTUM   AND   PELVIS. 


Rydygier's  osteoplastic  incision  is  shown  in  Fig.  160.  By  it  the 
sacrum  is  turned  to  the  right  like  a  trap-door  and  replaced  after  the 
operation.  It  certainly  diminishes  the  deformity  of  the  pelvis  caused 
by  the  operation,  but  I  have  always  thought  it  also  increased  the 
risk  by  rendering  drainage  less  perfect. 

The  work  thus  far  done  constitutes  merely  the  preliminary  inci- 
sion, and  should  be  completed  in  much  less  time  than  it  takes  to  de- 


FiG.  160. 

Rydygier's  Osteoplastic  Resection. 

a  b — Skin  Incision. 

c  d — Skin  and  Sacral  Incision. 


scribe.  Until  after  the  end  of  the  sacrum  has  been  removed  no  atten- 
tion need  be  given  to  hemorrhage,  except  what  an  assistant  can  give 
by  pressure  of  sponges.  The  bleeding  will  be  mostly  venous  and  not 
very  severe  ;  most  of  it  will  be  found  to  have  ceased  by  the  time  the 
bone  has  been  removed. 

Should  there  be  a  steady,  persistent  loss  of  blood  from  Just  un- 
der the  stump  of  the  sacrum,  it  will  be  from  the  sacral  plexus  of 
veins  and  it  may  be  very  annoying.  It  may  be  controlled  by  the 
pressure  of  an  assistant's  finger,  or  by  a  long  pair  of  forceps  slightly 


kraske's  excision  of  the  rectum. 


297 


Fig.  161. 
Posterior  View  of  Rectum  in  Male. 


298  SURGEEY   OF   THE   RECTUM   AND   PELVIS. 

curved,  or  by  a  ligature  passed  under  it  with  a  needle,  but  tying  in 
the  usual  way  without  a  needle  is  often  impossible.  Attention  is 
called  to  this  little  point  because  it  is  often  a  troublesome  one. 
When  the  rectum  has  been  removed  the  bleeding  will  generally  be 
found  to  have  ceased  spontaneously,  but  much  time  and  many  ounces 
of  blood  may  be  lost  in  unsuccessful  efforts  to  ligature  these  ves- 
sels, when  the  pressure  of  an  assistant's  finger  would  save  both. 

The  pelvis  is  now  freely  opened  and  the  operation  may  proceed. 

First  the  rectum  should  be  isolated  on  each  side  by  the  finger. 
'No  cutting  is  necessary,  as  the  gut  will  roll  out  of  its  bed  with  great 
ease  to  a  certain  extent  :  but  the  finger  cannot  be  passed  completely 
under  and  around  it  on  account  of  its  size  at  this  point,  nor  can  it  be 
drawn  down  at  all  on  account  of  the  firm  attachments  of  the  perito- 
neum and  the  mesorectum. 

Any  forcible  attemjDt  to  drag  it  down  at  this  stage  of  the  oper- 
ation is  attended  by  great  risk  of  rupture  and  consequent  soiling  of 
the  wound,  and  all  that  should  be  attempted  is  gentle  isolation  on 
each  side  by  separating  it  from  its  loose  attachments  with  the  finger, 
and  discovering  by  touch  the  extent  of  the  disease  to  be  removed, 
which  can  generally  be  easily  done  by  palpating  the  tube  as  it  lies  in 
the  wound. 

The  next  stej?  in  the  procedure  should  be  the  deliberate  opening 
of  the  peritoneal  cavity  as  near  as  possible  to  the  bottom  of  the  recto- 
vesical or  recto-vaginal  fold.  This  is  not  always  quickly  accom- 
plished, as  the  peritoneum  is  often  covered  by  a  considerable  layer 
of  connective  tissue,  and  this  may  be  nicked  several  times  at  various 
points  before  an  entrance  to  the  free  peritoneal  cavity  is  effected. 

As  the  operator  stands,  unless  he  is  ambidextrous,  the  most  fa- 
vorable point  for  opening  into  the  cavity  will  be  to  the  right  of  the 
gut,  high  up  in  the  incision,  as  the  gut  is  held  over  to  the  left  side 
by  an  assistant.  Care  must  be  taken  as  the  knife  or  scissors  are 
used  not  to  cut  into  the  gut  itself  instead  of  into  the  subperitoneal 
connective  tissue. 

When  once  the  peritoneum  has  been  opened  the  right  index  fin- 
ger may  be  passed  into  the  cavity,  hooked  under  the  gut  from  right 
to  left  and  forced  out  of  the  peritoneum  again  on  the  left  side  of  the 
gut,  and  into  the  wound.     In  this  way  the  upper  rectum  surrounded 


kraske's  excision  of  the  rectum. 


299 


£f-)\ 


'ii;- 


Fig.  162. 
Posterior  View  of  Rectum  in  Woman,  Peritoneum  Opened. 


300  SURGERY   OF   THE   RECTUM    AND    PELVIS. 

by  its  peritoneal  layer,  with  its  torn  margin  wliicli  went  to  make  tlie- 
cul-de-sac^  comes  into  the  wound  and  the  gut  is  freed  from  one  of  its- 
strongest  suspensory  ligaments. 

The  rectum  is  now  held  from  coming  down  only  by  the  meso- 
rectum,  which  binds  it  to  the  hollow  of  the  sacrum,  and,  while  gentle 
traction  is  made  upon  it  with  the  index  finger  under  it,  as  I  have 
described,  this  last  obstacle  to  its  free  descent  may  be  cut  away,  but 
this,  like  every  other  step  in  the  operation,  should  be  done  with 
precision  and  without  violence. 

It  must  be  borne  in  mind  that  the  nutrition  of  the  upper  end  of 
the  rectum  after  the  removal  of  the  disease  will  depend  entirely  upon 
the  tissue  which  is  now  being  cut,  and  this  nutrition  should  be  in- 
terfered with  as  little  as  possible.  The  bowel  should  not  be  forcibly 
stripped  off  from  the  mesentery  and  connective  tissue,  leaving  it  a 
mere  tube  without  sources  of  nourishment,  but  the  mesentery  should 
be  divided  with  scissors  at  some  little  distance  from  its  attached 
border,  so  that  any  vessels  coming  from  higher  up  and  running  par- 
allel with  the  gut  may  be  saved.  Large  veins  may  be  divided  be- 
tween double  ligatures  to  save  blood. 

The  rectum  has  now  been  rendered  freely  movable,  and  the  time 
has  come  to  resect  or  amputate  the  diseased  portion.  By  palpating 
the  gut  from  without,  the  upper  limit  of  malignant  disease  can  easily 
be  determined  ;  with  non-malignant  ulceration  it  may  often  be  neces- 
sary first  to  cut  across  the  bowel  above  the  strictured  and  thickened 
portion  and  then  to  remove  successive  sections  till  healthy  mucous- 
membrane  is  reached. 

Before  dividing  the  gut  a  ligature  of  gauze  or  an  intestinal  clamp- 
should  be  applied  above  the  point  of  section,  and  the  wound  should 
be  carefully  protected  with  packing  of  gauze.  The  cut  ends  should 
be  carefully  wiped  with  pledgets  of  gauze  and  dusted  with  iodoform, 
and  the  upper  one  should  be  intrusted  to  an  assistant  who,  by  cov- 
ering it  with  gauze  and  holding  it  out  of  the  way,  will  keep  from  in- 
fecting the  wound. 

The  lower  end  held  firmly  by  the  operator  must  then  be  rapidly 
dissected  from  its  remaining  anterior  attachments  and  either  cut  off" 
below  the  disease  or  removed  down  to  the  anus.  In  most  cases  of 
disease  within  reach  of  the  finger  by  rectal  examination,  the  latter 


kraske's  excision  of  the  rectum.  301 

will  be  necessary,  and  the  attachments  of  the  levator  on  both  sides 
must  be  cut  by  scissors  or  knife.  Bold  and  rapid  dissection  at  this 
stage  will  save  much  bleeding. 

During  all  this  part  of  the  operation  the  constant  danger  of  in- 
fecting the  wound  with  the  contents  of  the  divided  bowel  must  be 
scrupulously  guarded  against.  Up  to  this  time  complete  antisepsis 
is  easy,  but  at  this  stage  it  is  very  difficult,  and  yet  the  life  of  the 
patient  depends  most  certainly  upon  its  being  done  successfully,  for 
fouling  of  the  wound  with  intestinal  contents  means  high  fever,  pro- 
longed suppuration,  and  a  very  high  death-rate. 

After  removal  of  the  diseased  portion  it  ^lould  be  carefully  ex- 
amined. At  least  an  inch  of  healthy  gut  should  always  be  removed 
above  the  upper  limit  of  cancer,  and  in  non-malignant  disease  the 
mucous  membrane  of  the  cut  end  of  the  upper  segment  should  be 
rosy  and  healthy  in  appearance,  and  not  purple  and  ecchymosed. 

No  hemorrhage  need  be  feared  in  dividing  the  bowel.  Unfortu- 
nately, it  is  never  too  well  nourished,  and  a  bleeding  vessel  or  two  on 
section  is  always  a  good  sign. 

The  operator  will  find  he  now  has  the  whole  pelvic  cavity  at  his 
command.  In  women  the  tubes,  ovaries,  and  uterus  can  be  plainly 
seen  and  palpated.  Several  times  I  have  removed  tubes  and  ovaries 
at  this  stage  of  the  operation,  but  unless  their  removal  is  very  im- 
perative I  had  rather  not  do  so.  The  shock  of  an  extirpation  of  the 
rectum  may  be  more  than  the  patient  can  bear  without  any  addi- 
tional traumatism. 

The  next  point  to  be  decided  is  what  to  do  with  the  upper  end  of 
the  gut — whether  to  bring  it  down  to  the  skin  and  suture  it  in  the 
perineum,  to  suture  it  to  any  part  of  the  rectum  which  may  have 
been  left  below,  or  to  bring  it  out  in  the  middle  of  the  skin  incision 
and  suture  it  just  below  the  stump  of  the  sacrum.  This  is  always  a 
delicate  point,  and,  except  in  cases  of  disease  high  up,  where  a  dis- 
tinct resection  and  not  an  amputation  has  been  done,  and  where 
some  sort  of  end-to-end  union  is  to  be  attempted,  tlie  location  of  the 
new  anus  will  have  to  depend  more  upon  the  nutrition  of  the  upper 
fragment  than  upon  any  preconceived  ideas  of  the  operator. 

If  the  loose  end  of  the  gut  seems  well  nourished,  and  can  be 
loosened    from   its   attachments   sufficiently   to   allow   of  its   being 


302 


SUEGEEY   OF   THE   KECTUM   AND   PELVIS. 


Stitched  to  the  perineum  to  form  an  anus  in  the  normal  place,  it  will 
be  a  great  advantage.  If,  on  the  other  hand,  the  segment  is  pale 
and  bloodless  on  section,  if,  in  order  to  get  it  down  at  all,  the  mesen- 
tery has  been  freely  divided,  it  is  much  safer  to  bring  it  out  behind 
under  the  cut  edge  of  the  sacrum  and  attach  it  to  the  skin,  as  was 
originally  the  rule  in  all  cases. 

Of  course  an  anus  in  the  perineum   is   much  more  satisfactory 
than  one  in  the  sacral  region  ;  but  next  to  the  danger  of  infecting 


Fig.  163. 
Rectum  after  Excision. 


the  wound  during  the  operation  comes  the  danger  of  sloughing  of 
the  end  of  the  gut  after  the  operation,  and  infection  of  the  wound 
from  this  cause,  and  it  may  easily  happen  that  an  operation  will  be 
fatal  in  this  way  which  would  have  been  successful  had  the  operator 
been  content  with  a  little  less  perfect  after-result. 

In  cases  of  cancer,  where  all  questions  of  future  functional  per- 
fection are  as  nothing  to  the  great  one  of  prolonging  life  by  removing 
the  disease,  it  may  be  perfectly  proper  to  disregard  a  minor  point 
such  as  this  and  aim  simply  to  save  life  at  the  least  possible  risk  by 
forming  the  new  anus  in  the  sacral  region.     (Fig.  163.)     But  in  cases 


KKASKE  S    EXCISIOjVT    OF    THE    KECTUM. 


303 


of  non-malignant  stricture  and  ulcers  demanding  excision  the  sub- 
sequent functional  condition  of  the  parts  will  prove  a  matter  of  more 
consequence.  The  surgeon  may  know  he  has  as  surely  saved  the  life 
of  such  a  patient  as  if  he  had  removed  a  cancer,  but  the  patient  may 
not  appreciate  it,  and  nmy  be  tempted  to  compare  his  last  state  with 
his  former,  even  though  he  may  be  cured  of  his  disease  and  have 
gained  greatly  in  flesh  and  strength.  Therefore  it  is  always  better  to 
bring  the  upper  end  down  to  the  site  of  the  natural  anus  when  it  can 
be  done  without  too  much  danger  of  sloughing. 

This  point  having  been  decided  and  the  gut  fitted  to  the  position 
it  is  to  occupy,  and  lengthened  if  necessary  and  possible  to  avoid  ten- 
sion, or  shortened  if  more  remains  than  is  necessary  for  an  anus  in 


\^. 


Va  J^ 


Fig.  I(i4. 
Sacral  Artificial  Anus. 


the  sacral  region,  the  toilet  of  the  peritoneum  may  be  attended  to. 
This  is  much  the  same  as  in  an  ordinary  laparotomy— hot  douches 
with  saline  solution,  or  sponging  till  all  fluids  are  removed  from  the 
deep  portions  of  the  wound. 

Should  the  operator  prefer  to  close  the  opening  into  the  peri- 
toneum by  a  separate  catgut  suture,  this  should  next  be  done.  It 
is  not  difficult  to  find  the  ragged  margins  of  what  is  left  of  the  cul-de- 
sac,  run  them  together  by  a  continuous  suture  from  below  upward, 


304 


SUKGEllY   OF   THE   KECTUM   AND   PELVIS. 


and  finally  close  the  peritoneal  cavity  by  stitching  the  edges  of  the 
torn  peritoneum  to  the  peritoneal  layer  of  the  bowel.  I  do  not, 
however,  consider  this  separate  suture  necessary. 

The  end  of  the  gut  should  next  be  stitched  to  the  skin  at  the 
point  decided  upon,  and  all  parts  of  the  wound  should  be  drawn 
together  as  carefully  as  possible  by  deep  and  superficial  sutures. 
The  cavity  left  by  removal  of  the  rectum  is  too  large,  however,  for 


Fig.  165. 
Truss  for  Sacral  Anus. 


perfect  apposition  or  for  union  to  be  expected  by  first  intention,  and 
a  drain  of  aseptic  gauze  should  be  passed  down  to  its  deeper  parts. 
Free  oozing  will  always  take  place  from  the  bed  from  which  the  anal 
portion  of  the  gut  has  been  removed,  and  this  can  best  be  stopped  by 
a  few  deep  sutures  in  the  final  closure  of  the  wound.  In  fact,  it 
often  cannot  be  stopped  in  any  other  way. 

Usually  a  sharp  rise  of  temperature — to  102°,  or  even  102.5° — may 
be  looked  for  even  in  favorable  cases  at  the  end  of  the  second  day, 
but  in  those  that  are  to  do  well  this  will  subside  in  a  day  or  two 
spontaneously,  and  the  patient  will  make  an  uninterrupted  good  re- 
covery. A  successful  case  may  be  sitting  up  at  the  end  of  two 
weeks,  and  several  of  my  own  have  returned  to  their  homes  at  the 
end  of  three. 

The  most  careful  end  to  end  suturing  of  the  gut  after  the  removal 
of  the  disease  should  always  be  practised.     If  the  anus  has  also  been 


kraske's  excision  of  the  rectum.  305 

extirj)ated,  then  a  very  careful  suturing  of  the  end  of  the  gut  to  the 
skin  should  be  practised.  The  Murphy  button  is,  generally  speak- 
ing, not  adapted  to  these  cases  for  the  reason  that  its  successful  use 
depends  in  great  measure  upon  securing  peritoneal  approximation, 
and  there  is  usually  no  peritoneum  on  the  distal  end  of  the  gut  after 
extirpation  of  the  rectum. 

When  the  suturing  fails  the  vast  v^^ound  w^ill  be  found  after  two 
or  three  days  to  be  full  of  fetid  gas,  pus,  and  fecal  matter,  and  if 
the  patient  is  fortunate  enough  to  recover  it  is  v^itli  a  fecal  fistula  in 
addition  to  the  anus  provided  by  the  operation. 

In  cases  where  a  fecal  fistula  has  resulted  at  some  point  in  the 
line  of  incision,  secondary  plastic  operations  are  often  successful. 
As  a  rule  the  gut  itself  must  be  dissected  out  and  closed  with  Lem- 


FiG.  166. 
Truss  for  Sacral  Anus. 

bert's  suture,  and  then  the  wound  covered  by  suturing  the  skin  and 
subcutaneous  tissue.  Closing  the  skin  over  the  opening  in  the  bowel 
without  closing  the  opening  in  the  bowel  itself  is  seldom  successful. 

In  avoiding  fecal  fistula  trust  must  be  placed  entirely  in  a  care- 
ful suture  of  the  cut  ends,  and  the  more  careful  the  suture,  and  the 
more  perfect  the  antiseptic  precautions,  the  better  chance  there  is  of 
union  without  a  large  fecal  abscess  and  subsequent  fistula.    ' 

>  20 


306  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

In  amputation  the  upper  end  should  be  brought  as  near  the  site 
of  the  natural  anus  as  possible,  and  if  the  sphincter  has  been  left  the 
inside  of  the  anus  should  be  vivified  in  order  to  give  some  chance  for 
union.  Fecal  fistula  may,  it  is  true,  result  in  any  case,  but  the  main 
object  of  the  operator  should  be  to  avoid  this  result,  and  the  more 
thought  he  devotes  to  it,  and  the  more  perfect  his  antisepsis,  the  less 
likely  it  is  to  occur. 

8p?dncteric  Action  after  Extirpation. 

Many  attempts  have  been  made  to  secure  this  very  desirable  re- 
sult— most  of  them  ineffectual.  As  a  rule  there  will  be  no  sphinc- 
teric  action  after  an  amputation,  and  all  hopes  of  sphincteric  power 
after  destruction  of  the  muscle  upon  which  alone  it  depends  may  as 
well  be  abandoned  first  as  last.  The  twisting  of  the  end  of  the  gut 
before  suturing  it  to  the  skin  may  do  something,  and  so  may  an 
opening  in  the  substance  of  the  glutens  maximus  muscle  to  which 
the  end  of  the  gut  is  sutured,  but  it  is  best  not  to  hope  for  much 
from  these  expedients.  The  main  thing  to  be  hoped  for  is  the 
avoidance  of  any  contamination  of  the  wound  with  fecal  matter,  and 
I  can  only  say  with  regard  to  my  own  practice,  that  I  now  generally 
expect  a  patient  to  recover  from  the  operation  of  extirpation  of  the 
rectum,  and  that  by  careful  attention  to  all  the  details  of  antisepsis 
and  careful  suturing  of  the  end  of  the  gut  I  generally  make  out  to 
avoid  the  large  suppurating  cavities  full  of  fecal  matter  which  were 
formerl}^  the  chief  cause  of  death  after  my  own  operations. 

Provisional   Colostomy. 

Colostomy  is  of  much  greater  advantage  in  resection  than  in  am- 
putation. In  the  former  we  desire  not  only  to  have  the  site  of  oper- 
ation as  near  sterile  as  possible  before  the  operation,  but  especial- 
ly to  avoid  the  contact  of  fseces  for  as  long  a  period  as  possible 
after  the  operation  to  facilitate  union  of  the  approximated  edges. 
In  the  latter  class  of  cases  we  provide  a  free  outlet  for  the  fffices  and 
the  provisional  artificial  anus  is  less  necessary.  The  question  of  the 
amount  of  stricture  caused  by  the  malignant  growth  is  also  of  some 


kraske's  excision  of  the  rectum.  307 

importance.  Should  tliere  be  a  free  escape  of  faeces  the  gut  may  be 
rendered  comparatively  empty  by  catharsis  previous  to  the  opera- 
tion and  cleansed  in  the  manner  described  at  the  time  of  operation. 
On  the  other  hand  should  the  stricture  be  tight  there  is  sure  to  fol- 
low a  free  evacuation  from  the  overloaded  colon  which  greatly  com- 
plicates the  question  of  any  primary  union.  Were  it  not  for 
the  additional  shock  of  the  formation  and  subsequent  closure  of  the 
artificial  anus  I  confess  I  should  be  glad  to  take  advantage  of  the 
absence  of  faeces  in  the  wound  which  it  secures  in  all  cases. 

Many  complications  may  arise  during  an  operation  for  extirpation 
of  the  rectum.  One  of  the  most  awkward  I  have  ever  personally  en- 
countered was  to  find  a  rectum  absolutely  devoid  of  mesentery  and 
bound  immovably  to  the  hollow  of  the  sacrum.  All  attempts  to  get 
it  loose  and  bring  it  down  resulted  merely  in  stripping  up  one  of  the 
longitudinal  bands  of  muscular  fibres,  and  in  the  end  I  held  in  my 
hand  six  inches  of  stripped  and  injured  gut  which  was  entirely  with- 
out any  source  of  nutrition.  As  I  was  about  to  abandon  the  opera- 
tion and  turn  the  patient  over  for  a  left  inguinal  colostomy,  it  oc- 
cured  to  me  to  make  use  of  a  loop  of  large  gut,  probably  the  upper 
freely  movable  part  of  the  sigmoid,  which  during  a  great  part  of  the 
time  had  been  hanging  freely  in  the  field  and  occasionally  getting 
in  the  way.  This  was  drawn  into  the  incision  and  stitched  to  the 
edges  much  as  would  be  done  in  ordinary  colostomy.  It  was  then 
opened  and  the  section  between  this  opening  and  the  end  irrigated. 
Finally,  the  useless  end  of  the  gut  was  also  stitched  to  the  incision 
in  the  expectation  that  it  would  slough  and  come  away,  as  it  did. 
The  man  made  a  rapid  and  uneventful  recovery. 

Another  complication,  though  not  a  frequent  one,  may  be  found 
in  the  consolidation  of  all  the  perirectal  tissue  by  inflammatory 
changes  in  cases  of  old,  non-malignant  ulceration  and  stricture. 
Under  these  circumstances  the  isolation  of  the  rectum  may  be  a  mat- 
ter of  the  greatest  difficulty,  and  beyond  the  powers  of  the  inex- 
perienced operator. 

Such  in  brief  is  the  operation  for  extirpation  of  the  cancerous  or 
strictured  and  ulcerated  rectum.  The  most  casual  reader  will  at  once 
be  struck  by  the  fact  that  it  is  an  operation  of  absolute  precision, 
very  different  in  character  from  the  old  one  through  the  perineum, 


SOS  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

in  which  a  more  or  less  blind  plunge  was  made  into  the  pelvis  for  a 
piece  of  the  rectum,  and  in  which  the  loss  of  blood  depended  almost 
entirely  on  the  speed  of  the  operator. 

The  operation  described  may  be  done  by  an  experienced  man  in 
about  forty -five  minutes,  and  its  mortality  will  dej^end  much  more 
on  keeping  fecal  matter  and  other  intestinal  contents  out  of  the 
wound,  both  during  the  operation  and  the  first  days  of  healing, 
than  upon  the  amount  of  shock. 

My  own  first  statistics  showed  the  full  death-rate  of  thirty  per 
cent.,  but  by  attention  to  the  details  given  above  this  has  gradually 
been  reduced  until,  at  this  time  of  writing,  I  have  had  no  death  in 
the  last  seventeen  cases. 

A  wound  into  the  vagina,  though  always  to  be  avoided  when 
possible,  may  often  be  necessary  in  order  to  fully  remove  the  dis- 
ease. Such  a  fistula  may  be  closed  during  the  operation.  A  wound 
of  the  urethra  in  the  male,  when  slight,  is  to  be  treated  as  though 
the  patient  had  submitted  to  an  external  urethrotomy,  by  the  fre- 
quent passage  of  the  sound  to  prevent  contraction. 

When  a  large  piece  has  been  taken  from  the  urethral  wall,  a  per- 
manent recto-urethral  fistula  is  the  necessary  result,  and  the  danger 
of  fatal  inflammatory  action  is  greatly  increased  from  the  presence 
of  the  urine  in  the  rectal  wound.  Wounds  of  the  peritoneum  may 
or  may  not  be  sutured  with  catgut,  as  the  operator  prefers.  As  for 
the  cases  reported  by  Nussbaum  and  others,  in  which  the  whole 
neck  of  the  bladder,  the  greater  part  of  the  prostate,  and  the  seminal 
vesicles  have  been  removed,  and  the  patients  have  lived  for  years  in 
comfort,  they  are  merely  curiosities  of  literature.  That  such  a  thing 
may  happen  has  been  proved,  but  that  the  operation  should  ever  be 
undertaken  in  any  case  where  such  a  result  is  necessary  for  the  en- 
tire removal  of  the  disease,  has  yet  to  be  proved. 

In  certain  cases  where,  from  the  extent  of  rectum  removed,  it  is 
impossible  to  draw  the  ends  together,  or  where,  from  the  tightness  of 
the  stricture,  it  has  been  impossible  to  empty  the  bowel  above  of 
faeces,  or  where  the  wound  has  become  soiled  with  the  same  during 
operation,  Kraske  postpones  the  suturing  of  the  ends  of  the  gut  at 
the  posterior  segment  till  a  future  period,  and  forms  a  provisional 
sacral  artificial  anus,  as  shown  in  Figs.  163,  164.     For  this  a  subse- 


kraske's  excision  of  the  rectum.  809 

quent  plastic  operation  is  necessary.  Hoclienegg  has  devised  and 
applied  the  truss  shown  in  the  cut  for  use  in  these  cases.  (Figs.  165 
and  166.) 

Schede  accomplishes  the  same  end  by  a  colostomy  in  the  groin 
after  the  resection,  and  a  subsequent  closure  of  the  artificial  anus 
when  the  sacral  wound  has  healed. 


CHAPTER   XVIII. 

THE   FORMATION   AND   CLOSURE    OF  ARTIFICIAL   ANUS. 

The  indications  for  the  formation  of  an  artificial  anus,  which  are 
most  frequently  met  in  connection  with  rectal  surgery,  are  : 

Congenital  malformations. 

Intestino-vesical  or  vaginal  fistulse. 

Severe  ulceration  of  the  rectum. 

Cancer. 

Intestinal  obstruction. 

Tlie  rules  governing  the  attempt  to  form  an  artificial  anus  in  the 
perineum  in  cases  of  congenital  malformation  have  been  sufliciently 
dwelt  upon  in  the  chapter  devoted  to  that  subject.  Failing  to 
find  the  rectum  through  the  perineum,  or,  from  careful  study  of 
the  case,  deeming  it  best  not  to  make  the  attempt,  the  rule  is  to 
form  an  artificial  anus  in  the  left  groin. 

Attempts  at  establishing  an  anus  in  the  anal  region  after  the 
performance  of  colostomy  in  this  class  of  cases  are  attended  with 
greater  danger  than  the  original  operation,  and  are  not  generally 
successfnl.  They  involve,  when  successful,  also  the  closure  of  the 
artificial  anus.  I  have  had  two  fatal  cases  of  this  kind.  Mr.  Owen 
also  reports  two,  and  Byrd  and  Kronlein  each  a  successful  one. 

The  treatment  of  intestino-vesical  and  intestino-vaginal  fistulse 
has  already  been  described.     (See  Fistulae.) 

The  cases  of  severe,  non-malignant  ulceration  of  the  rectum,  with 
or  without  fistulse,  which  are  incurable  by  topical  treatment,  offer 
another  indication  for  the  formation  of  an  artificial  anus.  These 
ulcers  are  generally  either  tubercular,  or  the  result  of  simple  proctitis, 
and  many  of  them  are  as  incurable  as  though  they  were  cancerous. 

310 


THE   FORMATION    AND    CLOSURE   OF    ARTIFICIAL    ANUS.  311 

They  are  generally,  after  a  certain  time,  associated  with  stricture,  and 
the  patient  is  worn  out  by  chronic  intestinal  obstruction  joined  to  the 
exhaustion  occasioned  by  the  ulceration  with  its  pain  and  tenesmus. 
Many  of  these  cases  are  beyond  the  reach  of  cure  either  by  local  ap- 
plications of  any  sort  or  by  internal  medication.  IS'either  acids, , 
scraping,  nor  burning  will  do  any  good  after  the  disease  has  become 
of  large  extent,  and  the  internal  use  of  antisyphilitic  remedies  is 
generally  worse  than  useless. 

Colostomy  in  these  cases  will  prolong  life  indefinitely  by  relieving 
obstruction  if  it  exists,  and  by  allowing  the  rectum  to  become  quies- 
cent by  giving  another  outlet  for  the  faeces.  Ulcerations  which  have 
resisted  all  local  treatment  will  heal  by  this  means  ;  and  should  they 
not  heal,  will  cease  to  exhaust  the  patient  by  pain,  tenesmus,  and 
loss  of  sleep. 

It  is  better  to  admit  freely  the  limitations  of  our  art  in  these 
cases,  and  advocate  boldly  the  only  remedial  measure  in  our  power, 
than  to  go  on  trying  ineffectually  to  cure  old  and  incurable  ulcera- 
tions of  the  rectum  by  local  treatment. 

In  cancer  of  the  rectum  the  indications  for  colostomy  are  very 
clear,  and  there  seems  to  be  a  growing  tendency  to  earlier  operation, 
though  in  this  surgeons  will  differ  according  as  they  have  greater  or 
less  faith  in  certain  other  palliative  measures.  The  result  of  my  own 
study  and  experience  is  tending  more  and  more  to  convince  me  of 
the  advantages  of  early  operation  in  prolonging  life  beyond  what  can 
possibly  be  expected  when  the  disease  is  left  to  its  own  course. 

The  statistics  of  every  operator  will  vary  according  to  the  class 
of  cases  upon  which  he  operates.  Bryant,  for  example,  the  man 
who  has  done  more  than  any  other  to  advance  the  operation,  reports 
a  very  heavy  mortality,  taking  all  of  his  cases  together ;  but  he  evi- 
dently operates  to  save  life  on  all  the  cases  in  which  it  is  plainly  in- 
dicated, regardless  of  the  condition  of  the  patient  or  the  looks  of  his 
statistics.  It  is  always  easy  to  estimate  the  risk  of  the  operation  be- 
forehand from  the  condition  of  the  patient. 

As  to  the  benefits  arising  from  the  operation,  too  much  can 
scarcely  be  said.  That  it  prolongs  life  by  the  relief  of  pain,  the  pre- 
vention of  obstruction,  and  retarding  the  growth  of  cancerous  dis- 
ease, is  beyond  question.     That  it  substitutes  in  many  cases  a  pain- 


312  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

less  death  for  one  of  great  agony  is  also  indisputable.  The  idea 
that  it  is  as  well  to  let  a  patient  die  as  to  subject  him  to  a  colostomy 
has  no  supporters  among  surgeons  who  have  had  any  experience 
with  these  cases. 

I  can  only  say  that,  after  trying  every  other  means  of  treatment 
and  being  obliged  to  admit  the  fruitlessness  of  them  all  except  extir- 
pation, I  came  very  early  to  admit  the  great  benefits  of  colostomy,  and 
have  never  performed  it  in  any  case  in  which  either  the  patient  or 
myself  has  afterward  regretted  it.  This  is  exceedingly  well  ex- 
emplified in  one  of  my  patients  upon  whom  I  did  the  operation  for 
non-malignant  disease.  The  rectum  has  so  far  healed  that  I  have 
offered  to  close  the  artificial  anus  ;  but  she  will  not  consent.  The 
memory  of  her  old  sufferings  is  too  vivid  and  her  present  comfort  too 
great.  . 

There  can  be  no  argument  in  favor  of  colostomy  so  strong  as  a 
single  experience  with  a  case  of  cancer  of  the  rectum  left  to  its  own 
course  and  termination  in  fatal  obstruction ;  and  I  think  that  no 
matter  how  strong  one's  prejudice  against  an  artificial  anus  may  be, 
a  single  case  of  this  kind  will  convert  him.  There  is  no  more  painful 
death,  and  no  class  of  cases  in  which  the  surgeon  appears  at  a  more 
hopeless  disadvantage. 

Colostomy  should  not,  however,  be  looked  upon  merely  as  a 
means  of  preventing  obstruction  or  of  overcoming  it  when  actually 
present.  The  operation  fulfils  other  indications,  and  though  not  a 
very  dangerous  one  when  done  early,  the  mortality  is  greatly  in- 
creased by  waiting  till  obstruction  has  set  in. 

Again,  delay  may  cost  a  patient  his  life,  for  the  hour  when  a 
chronic  obstruction  will  change  into  a  fatal  condition  can  never  be 
foretold,  and  after  chronic  obstruction  has  set  in  the  dangers  of 
colostomy  are  greatly  increased. 

The  other  cases,  directly  connected  with  the  rectum,  in  which  it 
may  be  necessary  to  create  an  artificial  anus,  are  those  of  acute  or 
chronic  intestinal  obstruction.  In  the  formation  of  an  artificial  anus 
the  left  groin  should  be  chosen  for  the  site  of  the  operation. 


THE   FORMATION   AND   CLOSURE   OF   ARTIFICIAL   ANUS.  313 

Colostomy. 

Against  the  operation  of  lumbar  colostomy  there  have  always  been 
several  serious  objections.  The  ground  on  which  it  was  advocated, 
that  by  it  the  colon  could  be  reached  behind  the  peritoneum,  was 
often  false,  for  the  peritoneum  was  frequently  wounded  in  the  at- 
tempt to  reach  the  gut.  The  anus  thus  formed  is  awkwardly  placed 
for  the  patient,  so  that  he  can  exercise  but  little  care  over  it  without 
assistance.  The  operation  of  closing  the  fecal  fistula  thus  formed  is 
a  very  difficult  one. 

In  children  the  loin  operation  presents  still  greater  difficulties,  for 
the  undeveloped  state  of  the  colon  renders  it  much  more  difficult  to 
find  than  in  adults,  it  presents  many  variations  in  position,  and  the 
relatively  large  size  of  the  kidney  greatly  decreases  the  space  in 
which  the  operator  is  obliged  to  search.  In  the  child,  too,  the  de- 
scending colon  is  almost  completely  surrounded  by  peritoneum. 

In  fact,  the  lumbar  operation  owed  its  popularity  entirely  to 
the  false  dread  which  so  long  existed  against  incising  the  perito- 
neum. This  dread,  and  the  surgery  based  upon  it,  have  fortunately 
become  things  of  the  past. 

Nevertheless  the  lumbar  operation  is  applicable  to  cases  of  dis- 
ease of  the  sigmoid  flexure  and  of  the  colon  in  which  the  inguinal 
incision  would  be  below  the  disease,  and  it  is  also  much  easier  to 
perform  than  the  inguinal  in  cases  of  great  distention  from  obstruc- 
tion, and  for  this  reason  it  will  never  pass  entirely  out  of  practice. 

Operation  of  Lumbar  Colostorny. 

The  guide  to  the  descending  colon  is  the  outer  border  of  the 
quadratus  lumborum  muscle,  and  the  guide  to  the  outer  border  of 
the  muscle  is  a  perpendicular  from  a  point  half  an  inch  posterior  to 
the  middle  of  the  crest  of  the  ilium,  or  to  a  point  half  an  inch  posterior 
to  the  middle  of  aline  drawn  from  the  anterior  superior  to  the  poste- 
rior superior  spinous  process.  This  point  should  first  of  all  be  ac- 
curately determined  and  marked  with  ink  or  iodine,  for  the  edge  of 
the  muscle  cannot  easily  be  felt  in  many  subjects.  The  descending 
colon  is  here  sometimes  uncovered  by  peritoneum  to  a  considerable 


314 


SUKGEIIY   OF   THE   KECTUM   AND   PELVIS, 


extent,  being  behind  that  membrane  and  in  immediate  contact  with 
the  transversalis  fascia.  The  patient  should  be  placed  upon  a  hard 
pillow,  so  that  the  loin  may  be  brought  into  prominence,  and  the 
operator  should  stand  at  the  back  of  the  patient. 

The  incision  should  cross  the  edge  of  the  quadratus  obliquely 
from  above  downward  and  from  behind  forward,  beginning  at  the 
left  of  the  spine  below  the  last  rib,  and  extending  four  or  five  inches. 


Fig.  167. 
Incision  for  Lumbar  Colostomy. 


(Fig.  167.)  In  this  way  the  middle  of  the  outer  border  of  the  muscle 
will  correspond  to  the  middle  of  the  incision,  and  the  large  branches 
of  the  spinal  nerves  will  not  be  severed. 

The  incision  is  then  carried  carefully  down,  layer  by  layer, 
through  the  latissimus  dorsi,  external  and  internal  oblique,  and 
transversalis  muscles,  till  the  outer  border  of  the  quadratus  is  recog- 
nized ;  care  being  taken  that  as  the  incision  grows  deeper  it  does  not 
also  grow  shorter,  till,  when  the  bowel  is  reached,  the  operator  finds 
himself  working  in  the  small  end  of  the  funnel. 


THE   FORMATIOlSr   AND   CLOSURE   OF   ARTIFICIAL   ANUS. 


315 


If  possible  the  outer  border  of  the  quadratus  should  be  dis- 
tinctly recognized  before  the  transversalis  fascia  is  divided,  under 
which  lies  the  colon  more  or  less  enveloped  in  fat.  This  incision 
should  not  be  more  than  three  inches  in  length,  for  by  limiting  it  to 
this  extent  the  operator  is  in  a  manner  compelled  to  come  down 
upon  the  point  required  at  which  the  colon  is  most  likely  to  be 
reached,  and  great  weakening  in  the  abdominal  wall  and  consequent 
prolapse  are  avoided,  and  considerable  sphincteric    power  may  be 

gained. 

Having  reached  the  gut,  great  care  must  be  used  in  selecting  the 
piece  to  be  opened,  for  it  is  an  easy  matter  to  incise  the  duodenum 


Fig.  168. 
Lumbar  Colostomy. 


instead  of  the  colon.  No  piece  of  intestine  should  be  opened  until 
the  longitudinal  bands  in  it  have  been  clearly  recognized.  If  this 
can  be  done  to  the  operator's  satisfaction  without  wounding  the  peri- 
toneum, so  much  the  better  ;  but  otherwise  it  is  much  safer  to  in- 
cise the  serous  membrane,  pass  the  hand  into  the  abdomen,  and 
make  sure  that  the  colon  and  not  the  small  intestine  is  being  oper- 
ated upon. 

In  a  certain  proportion  of  cases  the  ascending  and  descending 
colon  will  be  found  destitute  of  mesentery,  and  hence  uncovered  by 
peritoneum  for  a  portion  of  the  posterior  wall,  as  shown  in  Fig.  169. 
This  proportion  is  given  differently  by  different  investigators.  Treves 
places  it  at  seventy-four  in  one  hundred  cases  on  the  right  side  and 
sixty-four  in  one  hundred  on  the  left.     In  other  words,  in  only  a 


316  SUEGERY   OF   THE   KECTUM   AND   PELVIS. 

small  proportion  of  all  cases  can  either  the  ascending  or  descending 
colon  be  opened  without  first  incising  the  peritoneum.  My  own 
preference  for  the  inguinal  operation  is  so  strong  that  I  have  never 
taken  the  trouble  to  verify  these  figures. 


Fig.  169. 
Colon  without  Mesentery. 


In  a  certain  other  proportion  of  cases,  represented  by  Fig.  170, 
the  ascending  and  descending  colon  have  a  short  mesentery,  or,  in 
other  words,  are  completely  covered  by  peritoneum,  so  that  they  can 
neither  be  seen  nor  reached  without  opening  the  peritoneal  cavity; 


Fig.  170. 
Colon  with  short  Mesentery. 

and  in  still  others,  shown  in  Fig.  171,  there  is  a  long  mesentery  al- 
lowing free  motion  of  the  colon. 

These  cases  show  how  impossible  it  may  be  to  reach  the  bowel 
without  incising  the  peritoneum  and  introducing  the  hand  into  the 
abdomen. 

When  the  gut  has  been  found  it  should  be  stitched  to  the  edge  of 
the  skin  by  sutures  passing  through  the  serous  and  muscular  coats 


THE   FORMATION   AND    CLOSURE   OF   ARTIFICIAL   ANUS.  317 

before  opening  tlie  bowel.  These  should  be  about  a  quarter  of  an 
inch  apart.  It  is  better  to  delay  opening  the  bowel  for  at  least  forty- 
eight  hours,  unless  the  obstruction  is  so  severe  as  to  render  the  op- 
posite course  necessary. 

It  is  of  great  importance  in  this,  as  in  inguinal  colostomy,  to 
make  so  sharp  a  spur  in  the  posterior  wall  as  to  prevent  the  passage 
of  faeces  into  the  distal  end  past  the  artificial  anus.  If  the  bowel  can 
be  drawn  well  out  of  the  wound,  this  may  be  accomplished  by  pass- 
ing a  suture  underneath  it,  drawing  it  tight,  and  securing  it  to  the 
edges  of  the  incision.  The  suture  may  be  passed  through  the  mesen- 
tery close  under  the  bowel,  if  the  mesentery  can  be  reached  ;  other- 
wise it  may  be  passed  through  the  muscular  coat  of  the  gut.     Failing 


Fill.  171. 
Colon  with  Long  Mesentery. 

to  do  this,  the  bowel  should  be  drawn  well  out  of  the  wound,  so  that 
in  the  undistended  gut  at  least  two-thirds  of  its  calibre  shall  be  out- 
side of  the  line  of  sutures.  In  this  way  a  sharp  bend  and  a  good 
spur  are  secured. 

Inguinal  Colostomy . 

The  operation  in  the  left  groin  is  to  be  preferred  in  all  cases  ex- 
cept those  of  great  abdominal  distention.  It  is  attended  by  no 
greater  danger  than  the  lumbar  operation,  and  in  other  respects  has 
many  advantages.  It  is  easier  of  performance ;  the  anus  is  so 
situated  that  the  patient  can  better  care  for  it  and  secure  cleanli- 
ness;  it  is  more  easily  closed  by  a  subsequent  operation;  it  allows 
the  terminal  portion  of  the  gut  to  be  more  easily  cleared  of  any  fecal 
matter  wdiich  may  collect  in  it. 


318  SUKGERY  OF  THE  RECTUM  AND  PELVIS. 

This  operation  permits  also  of  considerable  choice  in  the  part  of 
the  sigmoid  flexure  to  be  opened.  The  opening  may  be  made  low 
down  toward  the  rectum  or  high  up  toward  the  colon — so  high  that 
only  a  few  inches  of  the  gut  shall  intervene  between  the  opening  in 
the  groin  and  the  place  that  would  be  occupied  by  one  in  the  loin  ; 
and  should  the  descending  colon  be  found  diseased,  the  transverse 
may  be  easily  drawn  over  to  this  incision  and  opened.  This  I  have^ 
done. 

Inguinal  Colostomy. 

The  instruments  necessary  are  : 

Knife. 

Eight  pairs  of  artery  forceps. 

Blunt-pointed  scissors. 

Needle-holder. 

Medium  full-curved  Hagedorn  needles. 

Fine  straight  Hagedorn  intestinal  needles. 

Fine  black  silk. 

Fine  catgut. 

Silk-worm  gut. 

Two  perforated  shot  and  shields. 

Forceps  for  squeezing  shot. 

Two  dissecting  forceps. 

The  incision,  Fig.  172,  should  be  two  and  a  half  inches  long,  two 
inches  from  the  anterior  superior  spine,  and  across  an  imaginary  line 
from  the  anterior  superior  spine  to  the  umbilicus. 

Open  the  peritoneum  between  two  pairs  of  forceps  in  the  usual 
manner.  Catch  and  hold  its  free  cut  edge  at  the  lower  and  upper 
angles  of  the  incision  and  at  two  points  between  on  each  side,  leav- 
ing the  six  forceps  attached.  Pass  a  Hagedorn  needle  threaded  with 
silk-worm  gut  and  armed  with  a  perforated  shot  at  the  end  com- 
pletely through  the  abdominal  wall  from  without  inwards  at  a  point 
one  inch  from  the  free  margin  of  the  incision  toward  the  median  line 
and  rather  nearer  the  lower  than  the  upper  angle  of  the  wound.  Bring 
the  needle  out  of  the  cut  and  lay  it  still  threaded  on  the  abdomen. 
Next  find  the  sigmoid  flexure  and  bring  a  knuckle  of  it  out  of  the- 
wound.     Hold  this  piece  of  gut  between  the  fingers  of  the  left  hand 


THE    FORMATION    AND    CLOSURE    OF    ARTIFICIAL    ANUS. 


319 


and  pass  the  threaded  needle  through  its  mesentery  as  near  as  possi- 
ble to  the  gut  without  wounding  it.  Then  carry  the  needle  through 
the  abdominal  wall  from  within  outward  at  a  point  corresponding  to 


Fig.  172. 
Inguinal  Colostomy. 


the  point  of  entrance,  only  on  the  opposite  side  of  the  incision,  draw 
it  taut  and  secure  it  with  a  perforated  shot. 

In  this  wa}^  a  suture  is  passed  under  the  gut,  which  will  cause  it 


Fig.  173. 
Inguinal  Colostomy. 

to  bend  sharply,  and  at  the  same  time  the  sides  of  the  incision  are 
drawn  together  and  firmly  held. 

Next  suture  the  gut   to  the  cut  edges  of  the  peritoneum  of  the 
incision,   and  both  to  the  margins   of  the  skin  incision.      The  fine 


320 


SURGERY    OF   THE   RECTUM   AND   PELVIS. 


black  thread  is  used  for  this  purpose  and  the  stitch  is  passed  first 
through  the  margin  of  the  skin,  next  through  the  corresponding 
margin  of  tlie  parietal  peritoneum,   and  finally  througli  the  peri- 

(Fig.  174.)     The  needle  does 


toneal  and  muscular  wall  of  the  gut. 


Fig.  174. 
Inguinal  Colostomy. 


not  enter  the  cavity  of  the  gut  nor  is  the  muscular  layer  of  the  ab- 
domen included  in  the  stitch. 

When  such  a  stitch  is  tied  the  peritoneum  of  the  gut  will  be 
brought  into  contact  with  the  parietal  peritoneum,  and  both  with 
the  margin  of  the  skin  ;  and  the  general  peritoneal  cavity  will  be 
closed  at  this  point. 

About  eight  such  sutures  should  be  passed,  one  at  each  end  of 
the  cut  and  three  on  each  side.  Whenever  possible  the  stitch  should 
include  the  longitudinal  band  of  the  gut,  which  can  always  be  plain- 
ly seen.  As  the  stitches  are  secured,  the  forceps  holding  the  edges 
of  the  parietal  peritoneum  may  be  removed. 

In  this  way  the  selected  knuckle  of  intestine  drawn  well  out  of 
the  wound  is  firmly  secured  with  peritoneum  against  peritoneum, 
the  general  peritoneal  cavity  is  closed,  and  the  strain  is  taken  off  the 
fine  silk  sutures  b}^  the  silk-worm  suture  passed  through  the  whole 
thickness  of  the  abdominal  wall  and  under  the  intestine.  Should 
any  appendices  epiploicse  hang  free  in  the  wound  they  may  now  be 
tied  off  and  cut  away  and  the  gut  may  be  opened.     This  is  best  done 


THE   FORMATION   AND   CLOSURE   OF   ARTIFICIAL   ANUS. 


321 


with  scissors.  A  small  opening  is  made  in  the  knuckle  of  intestine 
near  the  upper  edge  of  the  wound,  a  linger  is  passed  into  this  for  a 
guide,  and  the  projecting  part  of  the  gut  trimmed  away  down  to 
within  a  quarter  of  an  inch  of  the  margin  of  the  skin. 

When  the  bowel  has  been  opened  the  appearance  of  a  double- 
barrelled  gun,  shown  in  Fig.  173,  with  the  lower  orifice  smaller  than 
the  upper,  becomes  evident. 

The  silk-worm  suture  may  be  removed  at  the  end  of  the  fourth 
day,  when  firm  adhesions  have 
taken   place  ;  the  others   may 
be  left   to  find  their  own  way 
out.     The   opening   is   dressed 
merely  with   a   piece   of  sheet 
lint  and  vaseline,  and  pad  and 
bandage.     By   the  end   of  the 
tenth  day  the  patient  is  gener- 
ally up  and  about,  and  is  con- 
valescent in  two  or  three  weeks. 
It  will  occasionally  happen, 
no   matter   how   great  care  be 
taken   in   the   formation   of    a 
spur,  that  faeces  will  pass  the 
artificial  opening  and   occupy 
the  diseased  rectum.     To  avoid 
this,  I   now,  in  cases  of  incu- 
rable  disease    (chiefly   cancer- 
ous) frequently  adopt  the  plan 
of  completely  dividing  the  gut, 
invaginating    the    lower    end, 
and  suturing  the  upper  to  the 
skin  incision.      When   this  is 
done  it  should  never  be  taken 

for  granted  that  the  gut  presents  in  the  wound  in  its  natural 
position  and  direction.  It  may  easily  be  reversed  and  it  must  be 
exceedingly  awkward  to  invaginate  the  proximal  end  and  stitch  the 
distal  into  the  wound,  as  has  happened. 

Much  greater  care  is  necessary  in  the  technique  of  this  operation 

21 


Fig.  175. 
Artificial  Anus. 


322  SUEGEEY    OF   THE   EECTUM    AND    PELVIS. 

than  in  that  just  described.  After  the  peritoneum  has  been  incised 
and  secured  with  six  or  eight  artery  forceps,  it  should  be  stitched  to 
the  skin  all  around  the  incision  with  a  running  suture  of  black 
silk. 

Next,  the  sigmoid  should  be  found,  its  direction  verified,  and  the 
desired  loop  brought  out  of  the  incision.  The  wound  in  the  abdomen 
should  then  be  completely  closed  with  gauze  to  prevent  soiling  of  the 


r 

Fig.  176. 

Colostomy. 

Distal  End  of  Gut  Invaginated. 

peritoneum,  and  the  bowel  cut  comjDletely  across  down  to  the  mesen- 
tery. The  cut-surfaces  of  mucous  membrane  should  be  carefully 
wiped  with  pieces  of  dry  gauze  till  all  traces  of  fecal  matter  have 
been  removed.  The  proximal  end  is  given  to  an  assistant  to  hold, 
and  the  distal  is  invaginated  and  closed  with  a  continuous  Lembert 
suture  (Fig.  176).  The  packing  is  next  removed  from  the  wound,  the 
invaginated  end  reduced  to  the  abdominal  cavity,  and  the  operator's 
left  index  finger  passed  into  the  23roximal  end  as  a  guide,  and  held 
there  until  the  suturing  of  this  end  to  the  margin  of  the  wound  is 
completed  (Fig.  177).     A  continuous  suture  of   silk  is  best  for  this 


THE    FORMATION    AND    CLOSURE    OF    ARTIFICIAL    ANUS.  323 

purpose,  and  the  suture  includes  all  the  coats  of  the  bowel,  the  edge 
of  the  peritoneum  lining  the  incision,  and  the  skin.  A  dressing  of 
cotton  and  a  body  bandage  are  all  that  are  necessary. 

There  is  a  theoretical  objection  to  this  operation  in  that,  should 
the  anal  end  of  the  piece  of  gut  which  has  been  invaginated  and 


Pig.  177. 
Colostomy. 

dropped  also  become  entirely  closed  by  the  progress  of  the  disease, 
a  closed  sac  full  of  foul  discharge  for  which  there  is  no  escape  might 
be  formed  and  render  necessary  a  second  opening  of  the  abdomen. 
I  do  not  know  that  this  has  ever  happened,  but  it  has  occurred  to 
me  as  a  possible  complication. 

Another  way  of  securing  a  good  spur  is  shown  in  Fig.  178. 

The  operation  requires  a  long  mesentery,  but  is  then  easily  ac- 
complished. One  row  of  Lembert  sutures  is  generally  sufficient  on 
each  side,  though  many  prefer  a  double  row.  The  approximated 
surfaces  should  be  at  least  two  inches  in  length. 

In  the  after-treatment  of  the  opening  I  have  found  nothing  much 
better  than  a  dressing  of  greased  sheet  lint,  a  pad  of  cotton,  and  a 
wide  elastic  bandage.  I  generally  have  a  truss,  exactly  similar  to 
the  ordinary  truss  for  hernia,  with  a  hard  rubber  bulb  to  fit  the 
opening,  made  for  each  case  ;  but  most  of  the  patients  make  little 
use  of  it,  and  are  perfectly  comfortable  without  the  increased  press- 
ure it  affords. 


324 


SURGERY  OF  THE  RECTUM  AND  PELVIS. 


In  non-malignant  disease  it  is  well  in  the  operation  to  preserve  as 
much  of  the  circumference  of  the  gut  intact  as  possible,  in  case  it 
should  in  the  future  be  thought  advisable  to  close  the  artificial  anus. 
The  only  difference  in  operating  to  secure  this  end  is  to  include  less 
of  the  circumference  of  the  gut  in  the  row  of  sutures — making  the 
opening  only  large  enough  to  give  a  free  outlet,  and  making  the  in- 
cision in  the  gut  horizontal  rather  than  transverse. 


Fig.  178. 
Formation  of  Spur  in  Colostomy. 


After  the  operation  the  action  of  the  bowel  may  be  left  to  nature. 
Sometimes  during  the  operation  scybalous  masses  may  be  felt  in  the 
sigmoid  flexure,  and  these  are  an  additional  indication  that  the  large 
bowel  is  under  the  finger.  If  possible  I  always  prefer  to  have  these 
masses  above  rather  than  below  the  point  of  gut  to  be  opened,  for 
their  evacuation  is  then  easy  ;  and  when  in  the  distal  portion  they 
cause  pain  by  their  presence  and  may  have  to  be  washed  down  and 
out  with  the  syringe. 


THE    FORMATIOlSr    AND    CLOSURE   OF   ARTIFICIAL   ANUS.  325 

The  first  evacuation  may  occur  immediately  the  bowel  is  opened, 
or  may  be  delayed  several  days  or  even  a  week.  In  the  latter  cases 
there  has  probably  been  chronic  dilatation  and  obstruction,  and  some 
time  is  required  for  the  muscular  wall  to  recover  its  tone. 

With  regard  to  the  artificial  anus,  cases  of  sphincteric  action  have 
been  reported,  but  it  is  safer  not  to  promise  so  favorable  a  condition. 
In  none  of  my  cases  have  I  seen  anything  that  could  properly  be 
called  voluntary  control  of  the  evacuations.  This  does  not,  however, 
imply  that  these  patients  are  troubled  with  a  constant  involuntary 
evacuation  of  faeces,  for  such  is  not  the  case.  I  have  one  patient, 
indeed,  who  never  has  a  movement  more  than  once  a  week,  and  only 
after  a  laxative. 

When  the  patient  has  diarrhoea  there  will  be  a  constant  discharge 
of  fluid  faeces  till  the  diarrhoea  is  checked  ;  but  nnder  ordinary  con- 
ditions the  bowel  can  be  trained  to  move  at  a  regular  time  each  day, 
the  patient  is  easily  able  to  care  for  the  evacuation,  and  is  then  com- 
fortable for  the  balance  of  the  day.  Both  men  and  women  are  able 
to  attend  to  their  duties  and  enjoy  a  fair  degree  of  health;  and  in 
cancerous  disease  I  have  had  several  patients  live  beyond  four  years 
from  the  time  of  operation. 

I  have  had  some  curious  experiences  with  this  operation,  which 
may  be  of  interest.  The  greatest  practical  difficulty  I  have  ever  met, 
and  that  has  been  met  more  than  once,  is  to  find  the  sigmoid  flexure 
so  bound  down  into  the  iliac  fossa,  either  by  an  absence  of  the  normal 
mesentery  or  by  old  adhesions,  as  to  render  it  difficult  to  bring  it  up 
into  the  incision  and  stitch  it  there  so  as  to  make  a  good  anus. 

This  difficulty,  though  detracting  from  the  accuracy  and  beauty 
of  the  performance  of  the  operation,  has  never  but  once  been  insur- 
mountable, except  in  so  far  as  it  interferes  with  the  formation  of  a 
spur.  In  that  case  sigmoid  flexure  and  mesentery  were  both  so  in- 
volved in  cancerous  disease  that  I  preferred  to  open  the  transverse 
colon  and  stitch  it  to  the  incision. 

A  very  untoward  accident  happened  in  another  case.  The  only 
thing  noteworth}^  about  the  operation  was  that  the  gut  was  very  thin 
from  old  dilatation  and  obstruction,  and  that  the  intestine  was 
moderately  full  of  gas  and  solid  faeces.  AVhen  putting  in  the  sutures 
I  remarked  on  the  abnormal  thinness  of  the  gut,  and,  as  far  as  pos- 


326  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

sible,  these  were  placed  in  the  longitudinal  bands,  in  order  to  secure 
as  much  strength  as  possible. 

Twenty -four  hours  later  my  assistant  made  the  usual  visit  in  my 
place,  and  was  informed  by  the  nurse  that  about  an  hour  before  his 
arrival  there  had  been  a  sudden  gush  of  serum  which  had  saturated 
the  dressings.  Such  an  unusual  occurrence  led  him  to  remove  the 
layer  of  cotton  with  which  the  abdomen  was  covered,  and  exposed 
the  fact  that  about  five  feet  of  small  bowel  were  outside  of  the  abdo- 
men and  firmly  strangulated  by  the  abdominal  wound.  The  gut  was 
cold,  but  on  cutting  the  silk-worm  suture  the  circulation  at  once  re- 
turned and  the  mass  was  reduced  without  great  difficulty.  On  my 
arrival  I  found  the  sigmoid  still  fastened  to  the  incision  as  at  the 
time  of  operation,  except  where  three  of  the  sutures  had  torn  out, 
and  through  this  unprotected  point  the  protrusion  had  occurred. 
Sutures  were  passed  through  the  entire  thickness  of  the  gut  on  that 
side,  and,  when  it  was  once  more  firmly  secured,  it  was  opened  to 
prevent  further  accident.  The  man  made  an  uninterruptedly  good 
recovery. 

This  same  accident  happened  also  in  one  other  case,  and  ended 
fatally  from  the  gross  carelessness  of  the  house  physician  in  the 
hospital.  The  evisceration  was  not  discovered  till  it  had  been  out 
many  hours  and  the  patient  was  in  collapse.  Both  cases  were  due 
to  the  effort  to  dispense  with  as  many  sutures  as  possible,  and  thus 
shorten  the  time  of  the  operation.  This  is  my  only  case  in  which  a 
fatal  result  has  been  due  directly  to  the  operation. 

Another  case  was  unsuccessful,  but  from  no  fault  of  the  operation. 
The  patient  was  over  sixty  and  much  exhausted  with  the  cancerous 
disease.  When  the  abdomen  was  opened  it  was  found  partially  filled 
with  serum  ;  the  intestine  was  greatly  congested,  and  the  entire 
mesentery  was  infiltrated  with  cancer.  There  were  no  distended 
coils  of  gut,  both  large  and  small  bowel  being  empty  and  contracted. 
It  was  with  great  difficulty  that  a  piece  of  the  sigmoid  flexure  could 
be  stitched  into  the  abdominal  incision,  so  closely  was  it  bound  down 
by  cancerous  infiltration  of  the  mesentery,  and  a  loop  of  small  intes- 
tine w^hich  also  appeared  in  the  wound  was  onl}^  a  trifle  more  mov- 
able. The  large  intestine  was  chosen  and  with  difficulty  sutured,  the 
muscular  layer  being  very  friable.     The  patient  did  well  for  forty 


THE  FORMATION   AND   CLOSURE   OF   ARTIFICIAL   ANUS.  327 

hours,  when  severe  vomiting  began  and  the  temperature  steadily  rose 
to  105°  vt^ith  signs  of  collapse. 

The  wound  was  examined  and  found  in  good  shape  ;  the  bowel 
was  incised,  but  there  was  no  escape  of  gas  as  is  usual,  and  only  a 
small  quantity  of  faeces  was  found  by  introducing  the  finger  into  the 
proximal  end.  Death  followed  in  a  few  hours,  with  all  the  symptoms 
of  collapse,  and  on  opening  the  abdomen  a  complete  obstruction  with 
a  gangrenous  loop  was  found  in  the  large  intestine  at  the  splenic 
flexure. 

The  obstruction  was  due  to  a  band  of  cancerous  mesentery  which 
had  caused  a  sharp  flexure  in  the  gut,  which  flexure  was  completely 
obstructed  by  a  small  scybalous  mass.  Although  the  obstruction 
had  been  fatal  in  less  than  twelve  hours,  there  was  no  great  distention 
of  the  large  intestine  above  the  obstructed  point ;  and  though  I  had 
opened  the  gut  as  soon  as  the  vomiting  began,  under  the  impression 
that  the  symptoms  might  be  due  to  the  complete  obstruction  caused 
by  the  operation,  the  failure  to  find  any  obstruction  at  the  wound, 
joined  to  the  fact  of  a  temperature  of  105°,  led  me  to  suppose  that 
the  patient  was  dying  of  septic  peritonitis. 

In  some  cases  after  the  operation  an  annoying  prolapse  of  mucous 
membrane  will  occur.  This  has  seldom  been  an  element  of  trouble  in 
any  of  my  cases,  and  I  attribute  the  fact  to  the  drawing  down  of  the 
upper  part  of  the  coil  firmly  before  attaching  it  to  the  skin.  The 
prolapse  may,  however,  come  from  either  the  proximal  or  distal  por- 
tion of  the  gut  or  from  both,  and  may  reach  such  a  degree  as  to  de- 
mand further  operative  interference. 

Under  such  circumstances,  rather  than  amputate  the  prolapsed 
gut,  I  prefer  to  reopen  the  abdomen  at  the  side  of  the  original  incision 
by  prolonging  it  an  inch  or  so  at  either  the  upper  or  lower  end,  dis- 
sect the  gut  entirely  loose  from  its  attachments,  divide  it  across, 
trim  the  distal  end,  invaginate  it  and  drop  it  into  the  pelvis  ;  and 
then,  after  trimming  the  proximal  end,  attach  that  to  the  abdominal 
wall  and  close  the  remainder  of  the  abdominal  incision.  This  has 
worked  well  in  the  few  cases  in  which  I  have  been  called  upon  to  re- 
lieve the  condition. 


328  SURGERY    OF   THE    RECTUIM    AND    PELYIS. 

Tlie  Closure  of  Artificial  Anus  and  Fecal  Fistula. 

An  artificial  anus  is  now  so  frequently  made  as  a  temporary 
measure  of  safety  in  the  performance  of  more  serious  surgical  opera- 
tions upon  the  alimentary  canal,  or  to  tide  a  patient  over  the  stage 
of  collapse  in  intestinal  obstruction,  that  its  subsequent  closure 
becomes  a  matter  of  frequent  necessity. 

Fecal  Fistula. 

The  distinction  between  an  artificial  anus  and  a  fecal  fistula  is  usu- 
ally considered  to  be  that  the  former  is  made  intentionallj^  by  the  sur- 
geon, while  the  latter  is  the  result  of  a  pathological  process  which  has 
destroyed  a  portion  of  the  canal  of  greater  or  less  extent.  Many  an 
attempt  to  form  a  useful  artificial  anus  has  resulted,  however,  merely 
in  the  production  of  a  fecal  fistula  which  it  is  very  difiicult  to  keep 
from  closing  spontaneousl3^ 

Fecal  fistula  may  result  from  many  causes,  the  most  frequent  of 
which  are  traumatism  to  the  intestine  in  the  performance  of  pelvic 
surgery,  and  abscesses  in  the  pelvis  or  around  the  appendix. 

The  abscess  may  be  the  primary  cause  of  the  trouble  resulting  in 
perforation  of  the  gut,  in  whicli  case  the  fecal  fistula  may  already 
exist  before  the  abscess  is  evacuated  by  the  surgeon  ;  or  the  perfora- 
tion of  the  gut  from  ulceration  or  from  traumatism  in  an  abdominal 
or  pelvic  operation  may  precede  the  formation  of  the  abscess. 

Other  known  causes  of  fecal  fistula  are  : 

Strangulation  of  the  gut  in  hernia. 

Foreign  bodies. 

Gunshot  or  penetrating  wounds. 

Cancerous  deposits. 

Actinomycosis  in  the  intestine. 

The  complicating  condition  in  the  treatment  of  fecal  fistula  is  the 
presence  of  the  abscess  cavity.  Were  it  not  for  this  a  simple  plastic 
operation  would  cure  most  of  those  which  do  not  close  spontaneously 
or  are  not  due  to  cancerous  destruction;  and  the  treatment  often 
divides  itself  necessarily  into  two  factors,  the  closure  of  the  fistula 
and  the  cure  of  the  abscess. 


THE  FORMATION   AND    CLOSURE   OF   ARTIFICIAL    ANUS.  329 

Many  fistulse  of  this  kind  close  spontaneously  or  with  stimulating 
the  cutaneous  orifice.  These  are  the  ones  in  whicli  nature  has  for- 
tunately failed  to  bring  the  gut  close  to  the  skin  and  line  the  external 
orifice  with  mucous  membrane,  as  it  is  always  the  object  of  the  surgeon 
to  do  in  the  formation  of  an  artificial  anus. 

Treatment  is  therefore  carried  out  on  the  following  principles  : 

Before  any  operation  is  undertaken  time  should  be  given  for  the 
fistulous  tract  to  close  spontaneously,  or  as  a  result  of  stimulation. 

Should  the  discharge  of  pus  indicate  a  considerable  abscess  cavity 
this  should  be  opened  and  drained  and  eveiy  effort  made  to  induce  it 
to  heal,  in  the  hope  that  the  opening  into  the  gut  may  also  close. 

Should  these  measures  fail  the  fistula  must  be  laid  open  from  the 
skin  to  the  gut,  the  abscess  cavity  cleaned  out  with  as  great  protec- 
tion to  the  general  peritoneum  as  possible,  and  the  opening  into  the 
gut  freshened  and  sutured  if  possible,  or  else  resected. 

The  presence  of  the  abscess  and  consequent  infection  of  the  general 
peritoneum  is  the  cause  of  the  high  mortality  in  this  procedure,  and 
hence  it  is  not  to  be  recommended  till  all  other  methods  have  failed. 

Should  the  fistula  be  in  the  small  bowel  and  free,  rapid  emaciation 
may  compel  operation.  In  the  large  bowel,  however,  the  patient  may 
have  so  little  discomfort  that  radical  operation  need  not  be  urged. 

In  doing  a  colostomy  the  operator  should  always  have  a  very  def- 
inite idea  as  to  whether  the  opening  is  to  be  a  permanent  one  or  may 
be  closed  at  some  future  time  should  the  case  progress  favorably,  and 
regulate  his  work  accordingly.  If  the  opening  is  to  be  permanent, 
as  in  cancer  of  the  rectum  which  cannot  be  excised  for  example,  the 
wall  of  the  bowel  may  be  freely  excised  or  divided  transversely  and 
the  most  effective  outlet  possible  may  be  aimed  at ;  while  should  the 
opening  be  only  provisional,  a  mere  longitudinal  incision  into  the 
bowel  which  can  easily  be  sutured  by  a  secondary  operation  may 
answer  every  purpose. 

The  old  operation  for  closing  an  artificial  anus  consisted  first  in 
destroying  the  spur  by  means  of  pressure  forceps  (Figs.  179  and  180), 
and  subsequently  drawing  two  flaps  of  integument  over  the  outlet, 
but  with  the  bolder  surgery  of  to-day  these  older  methods  have 
passed  into  history.  The  presence  of  a  spur  sufficiently  large  and 
heavy  to  be  a  cause  of  obstruction  would  now  be  overcome  by  a  com- 


330 


SUKGEEY  OF  THE  KECTUM  AND  PELVIS. 


plete  resection  of  the  ends  of  the  gut  and  the  re-establishment  of  its 
continuity  by  some  form  of  suture.  This  would  be  much  safer  and 
more  surgical  than  to  establish  a  sloughing  process  within  the  ab- 
domen in  the  hope  that  it  might  proceed  just  far  enough  to  destroy 
the  spur  and  cease  before  a  fatal  peritonitis  was  set  up. 


Fig.  179. 
Condition  of  Bowel  after  Colostomy,  showing  Septum  and  course  of  Faeces. 


The  closure  of  the  orifice  may  be  accomplished  in  several  ways. 
If  the  wall  of  the  bowel  has  not  been  sacrificed  the  edges  may  be  dis- 
sected up  without  passing  beyond  the  adhesions  to  the  abdominal 
wall,  turned  into  the  lumen  back  to  back  and  the  opposing  serous 
surfaces  sutured.    The  edges  of  the  mucous  membrane  alone  may  be 


Fig.  180. 
Enterotome  of  Dupuytren  in  Position. 


treated  in  the  same  way  and  may  form  a  sufficient  covering  when 
the  skin  has  been  dissected  up  and  drawn  over  them. 

Szymanowski's  operation  for  the  closure  of  urethro-perineal  fis- 
tula may  also  be  applied  to  the  closure  of  artificial  anus.  The  steps 
in  the  operation  are  as  follows  : 

A  single  straight  incision  is  made,  from  A,  three-quarters  of  an 
inch  in  front  of,  to  B,  three-quarters  of  an  inch  behind,  the  fistula 
(Fig.  181).  This  incision  passes  through  skin  and  superficial  fascia, 
and  closely  skirts  the  right  side  of  the  fistula.     The  edge  of  this  in- 


THE   FORMATION   AND    CLOSURE    OF   ARTIFICIAL   ANUS. 


331 


cision is  raised,  and,  working  with  a  small  blade  to  the  patient's  right 
side,  the  skin  and  fascia  are  undermined  until  a  pocket  is  formed 
including  the  area  A  C  B  F,  the  right  edge  of  the  pocket  being  indi- 
cated by  the  dotted  line  A  C  B  (Fig.  182). 

On  the  opposite  side  a  curved  incision,  A  D  B,  is  then  made,  the 
greatest  width  of  the  flap  thus  marked  out  being  three-quarters  of 
an  inch  to  one  inch. 

This  flap  must  be  generous  and  should  include  a  good  padding  of 
fascia,  as  when  it  is  lifted  the  shrinkage  is  great. 


C; 


C: 


B 

Fig.  18L 
Szymanowski's  Operation. 
First  stage. 


B 

Fig.  183. 
Szymanowski's  Operation. 
Second  Stage. 


Before  lifting  the  flap  a  thin  layer  of  skin  is  removed  from  its 
surface.  This  is  best  done  with  small  curved  scissors,  the  super- 
ficial layer  of  skin  being  rapidly  chipped  off. 

The  freshening  process  is  carefully  extended  over  the  entire  area 
A  D  B  F,  excepting  over  a  surface  a  little  larger  than  the  fistula,  and 
immediately  next  to  it. 

The  flap  A  D  B  is  then  dissected  up  close  to  the  median  line  and 
inverted,  its  attached  edge  acting  as  a  hinge  and  as  a  medium  for 
blood-supply  (Fig.  182). 

Five  or  six  fine  catgut  sutures  are  passed  through  the  skin  at  dif- 
ferent points  a  little  beyond  the  dotted  line  A  C  B,  into  the  pocket, 
then  through  the  free  edge  of  the  flap,  and  then  back  into  the  pocket 


332 


SUEGERY  OF  THE   RECTUM   AND    PELVIS. 


and  out  through  the  skin.  Five  or  six  loops  are  thus  formed,  by 
drawing  upon  which  the  flap  is  closely  drawn  down  to  the  bottom  of 
the  pocket,  and  the  free  ends  of  the  loops  are  tied.  (See  Fig.  183.) 
Two  or  three  sutures  of  catgut  are  now  passed  with  a  curved  needle 


B 

Fig.  183. 
Szymanowski's  Operation. 
Third  Stage. 


B 

Fig.  184. 

Szymanowski's  Operation. 

Fourth  Stage. 


through  the  upper  surface  of  the  inverted  flap  so  as  to  firmly  bind  it 
to  the  parts  beneath.  Sometimes  with  interrupted  and  sometimes 
with  a  continuous  catgut  suture  the  free  edge,  A  F  B,  is  now  secure- 
ly fastened  to  the  edge  A  D  B. 


CHAPTER    XIX. 

INTESTINAL    RESECTION    AND    ANASTOMOSIS. 

All  methods  of  anastomosis  reduce  themselves  practically  to  two 
— end  to  end  and  lateral. 

Of  each  of  these  there  are  many  varieties.  No  effort  will  be  made 
to  describe  them  all,  only  those  being  selected  which  are  the  simplest 
and  most  efficient,  and  the  technique  of  which  should  be  fully  under 
the  control  of  every  man  who  ventures  to  open  the  abdomen  for  any 
purpose  whatever. 

The  present  tendency  of  surgical  opinion  is  against  the  use  of 
mechanical  appliances  in  anastomosis.  The  best  union  of  all  is  one 
made  by  the  needle  and  without  the  introduction  of  a  foreign  body. 
The  technique  of  these  operations  has  so  far  improved  that  the  only 
argument  left  in  favor  of  the  simplest  and  best  of  all  the  mechanical 
appliances,  the  Murphy  button,  is  that  by  its  use  time  may  be  saved  ; 
and  this  advantage  is  more  than  counterbalanced  by  the  risks  in- 
herent in  the  button  itself. 

The  element  of  time  may  be  exaggerated.  To  a  rapid  and  expe- 
rienced operator  the  time  saved  will  not  be  very  great.  Since,  how- 
ever, the  button  may  be  used  by  those  of  little  experience  in  intestinal 
surgery  who  have  no  time  in  an  emergency  to  send  for  an  experi- 
enced operator ;  and  since  it  occasionally  serves  a  good  purpose,  a 
description  of  the  method  of  using  it  will  not  be  omitted. 

Abbe's  Anastomosis. 
The  best  of  all  methods  of  lateral  anastomosis  is  that  devised  by 
Abbe.     The  instruments  necessary  besides  those  ordinarily  used  in. 
opening  the  abdomen  are  : 

333 


B34  SUEGERY   OF   THE   RECTUM   AND   PELVIS. 

Six  fine  cambric  needles. 

Fine  black  silk. 

Two  intestinal  clamps. 

Thumb  forceps. 

Artery  forceps. 

Catgut  for  ligatures. 

Straight  scissors. 

Flat  sponges. 

The  six  needles  should  each  be  threaded  with  the  black  silk 
twenty-four  inches  long.  Abbe  ties  the  thread  into  the  needle  with  a 
single  loop  and  cuts  one  end  short,  to  be  out  of  the  way. 

After  applying  the  clamps  and  resecting  the  diseased  intestine 
with  what  mesentery  may  be  necessar}^,  and  attending  to  the  hemor- 
rhage from  the  cut  mesenteric  margins,  the  ends  of  the  gut  are  in- 
vaginated  in  the  usual  way. 

Even  this  requires  a  little  skill  to  do  it  quickly  and  neatly.  The 
cut  end  of  the  gut  should  be  seized  with  thumb  forceps  in  one  hand 
while  the  gut  itself  is  held  firmly  between  the  thumb  and  finger  of 
the  other  hand  about  an  inch  from  its  extremity.  The  margin  can 
then  generally  be  turned  into  the  lumen  without  difficulty,  and  held 
there  between  the  thumb  and  finger  until  a  Lembert  suture  can  be 
introduced  and  close  permanently  the  cut  end  of  the  bowel. 

In  Abbe's  own  words,  we  next  "apply  two  parallel  rows  of  continu- 
ous Lembert  suture  a  quarter  of  an  inch  apart  and  an  inch  longer 
than  the  proposed  cut  (Fig.  185),  leaving  each  thread  with  its  needle 
attached  at  the  end  of  its  row.  Now  open  the  bowel  by  scissors,  cut- 
ting a  quarter  of  an  inch  from  the  sutures,  both  rows  of  which  are  to 
remain  on  one  side  of  the  cut  (Fig.  185). 

"Make  the  bowel  opening  four  inches  long.  Apply  clamps  tem- 
porarily to  several  bleeding  points,  pinching  the  entire  thickness  of 
the  cut  edge  without  hesitation.  Apply  no  ligatures.  Treat  the 
opposing  bowel  in  the  same  manner.  The  clamps  remaining  in  situ 
the  parts  are  quickly  rinsed  with  water.  Another  silk  suture  is  now 
started  at  one  corner  of  the  openings  and  unites  by  a  quick  over- 
hand, the  two  cut  edges  lying  next  the  first  rows  of  sutures.  The 
needle  pierces  both  mucous  and  serous  coats  and  thus  secures  the 
bleeding  vessels  from  which  the  clamps  are  removed  as  the  needle 


INTESTINAL    RESECTION    AND   ANASTOMOSIS. 


335 


336 


SURGERY   OF   THE   RECTUM   AND   PELVIS. 


INTESTINAL    KESECTION    AND   ANASTOMOSIS. 


337 


s     =« 
fe    ^ 


22 


338  SUKGERY    OF   THE   RECTUM   AND   PELVIS. 

reaches  them.  The  suturing  is  then  continued  round  each  free  edge 
in  turn,  and  all  bleeding  points  are  thus  secured  more  quickly  than 
by  ligature.  The  serous  surfaces  round  these  button-holes  are  then 
rapidly  secured  by  a  continuation  of  the  suture  first  applied,  the  same 
threads  being  used,  the  one  nearest  the  cut  edge  first ;  the  united 
parts  are  again  rinsed  with  water  and  dropped  into  the  abdomen." 

Instead  of  the  double  row  of  Lembert  sutures  used  b}^  Abbe  I 
have  employed  a  single  row  of  Lembert  sutures  with  perfect  result 
and  I  believe  a  saving  of  time  ;  for  by  this  method  and  without 
hurrying  I  have  completed  a  gastro-intestinal  anastomosis  in  thirty 
minutes. 

MaunseWs   Anastomosis. 

This  is  by  far  the  most  satisfactory  form  of  end  to  end  suture, 
the  only  objection  to  it  being  that  it  requires  considerable  mobility  in 
the  portion  of  gut  operated  upon  and  hence  is  not  always  applicable. 

The  instruments  necessary  are  the  same  as  in  Abbe's  operation, 
except  that  so  many  needles  are  not  necessary,  and  a  fine  Hagedorn 
needle  answers  as  well  as  any  other. 

Isolate  the  piece  of  gut  to  be  operated  upon,  strip  the  contents  out 
of  it  and  apply  the  clamps.  Resect  the  portion  necessary  and  its 
attached  mesentery  as  before. 

Select  a  point  in  either  the  proximal  or  distal  portion  of  the  gut, 
as  may  be  most  convenient,  about  six  inches  from  its  cut  end  and 
make  a  longitudinal  incision  an  inch  and  a  half  long  in  its  unattached 
border  (Fig.  188,  A). 

It  is  well  now  to  remove  the  intestinal  clamps  which  are  much  in 
the  way  during  the  subsequent  steps  and  trust  the  cut  ends  of  the 
bowel  to  assistants  to  prevent  leakage. 

Pass  a  strong  suture  through  the  two  ends  of  the  gut  from  with- 
in outward  at  B  and  from  without  inward  at  C,  and  include  the  cut 
edges  of  the  mesentery  in  the  loop.  Repeat  the  operation  with 
another  similar  suture  on  the  opposite  edges. 

Pass  a  long  pair  of  forceps  through  tlie  opening  A,  gather  the  ends 
of  the  sutures  in  its  grasp  and  bring  them  out  through  A. 

It  is  evident  that  when  the  four  strings  are  drawn  taut  and  pulled 
upon  the  cut  edges  CC  will  be  pulled  into  the  lumen  BB,  and  that 


INTESTINAL    KESECTION    AND   ANASTOMOSIS. 


339 


Fig.  188. 
Maunsell's  Anastomosis. 


cut  edge  BB  will  also  be  inverted  until  both  cut  edges  appear  through 
the  opening  A  with  their  serous  surfaces  in  contact. 

Pull  the  edges  B  and  C  well  out  through  the  opening,  and,  while 


Fig.  189. 
Maunsell's  Anastomosis.    Second  Step. 

a  finger  is  introduced  into  the  lumen  of  the  bowel  at  C  to  keep  the 
parts  in  relation,  run  a  close  overhand  silk  suture  through  all  the 
coats  of  both  B  and  C.       Cut  away  the  leading  strings,    carefully 

c  A 

— ^ 3- illlllillllllll 


Fig.  190. 
Maunsell's   Anastomosis  Completed 


340 


SUEGERY    OF    THE    KECTUM    AND    PELVIS. 


reduce  the  invagination  by  traction,  and  close  the  opening  A  with  a 
Lembert  suture  (Fig  190).  Finally  unite  the  cut  edges  of  the  mesen- 
tery. 

It  is  evident  that  both  these  forms  of  anastomosis  require  consider- 
able length  of  free  bowel  for  proper  coaptation  and  manipulation. 


Fig.  191. 
Lembert  Suture. 


Should  this  not  be  obtainable  a  simple  end  to  end  suture  may  be  done 
with  two  continuous  silk  sutures,  one  for  the  mucous  membrane  and 
another  for  the  muscular  and  serous  layers  combined. 


Forms  of  Suture. 

In  practice  all  forms  of  sutures  may  be  reduced  to  two,  the  Lem- 
bert shown  in  Figs.  191  and  192,  which  may  be  either  continuous  or 
interrupted,  and  the  combined  Czerny  and  Lembert  suture  shown  in 


INTESTINAL     RESECTION     AND    ANASTOMOSIS. 


341 


Fig.  193. 
Lembert  Suture. 


Fig.  193.  The  latter  consists  of  two  different  sutures,  one  uniting  the 
mucous  membrane,  which  ulcerates  through  into  the  calibre  of  the 
gut,  and  one  uniting  only  the  peritoneum,  which  becomes  encysted. 


Fig.  193. 
Czemy-Lembert  Suture. 


Many  more  elaborate  forms  of  suture  have  been  devised,  but  these 
two  will  answer  every  practical  purpose. 

The  end  to  end  suture  shown  in  Fig.  194  is  a  modification  of  the 


342 


SURGERY  OF  THE  RECTUM  AND  PELVIS. 


Czerny-Lembert,  in  which  the  Lembert  stitch  is  made  to  include  the 
muscular  layer  for  additional  strength. 

If   the   operator  prefer,    he   may   use   a  number  of  interrupted 
sutures  for  the  mucous  membrane  (about  four  to  the  inch)  and  all 


Fig.  194. 
End  to  End  Anastomosis, 

but  the  last  two  or  three  of  these  may  be  tied  with  their  knots  in  the 
calibre  of  the  bowel,  but  results  in  clinical  work  have  proved  that 
this  is  not  necessary. 

The  Murphy  Button. 

This  device  is  shown  in  Fig.  195,  and  its  method  of  application  in 
Fig.  196,  and  Fig.  197,  and  Fig.  198. 


Fig.  195. 
The  Murphy  Button. 

It  can  be  used  either  for  end-to-end  or  lateral  anastomosis,  but  for 
the  latter  an  oblong  button  at  least  an  inch  and  a  half  in  length  is 
much  better  than  a  circular  one,  and  in  any  case  the  openings  made 
by  this  mechanical  contrivance  are  apt  to  contract  so  as  to  cause 
stricture. 


INTESTINAL    RESECTION    AND   ANASTOMOSIS. 


343 


Fig.  196. 
Murphy  Button  in  Position,  ready  for  Closure, 


Pig.  197. 
Murphy  Button  Closed. 


344 


SUKGEEY   OF   THE   RECTUM   AND   PELVIS. 


Fig.  198. 
Appearance  of  Gut  after  Closure  of  Murphy  Button. 


Fig.  199. 
Lateral  Anastomosis  with  Murphy  Button,  showing  Incision  and  Draw-string. 


INTESTINAL    RESECTION    AND    ANASTOMOSIS.  345 

In  using  the  button,  care  must  be  taken  that  no  mucous  mem- 
brane shall  protrude  between  the  peritoneal  surfaces  after  the  button 
has  been  closed,  otherwise  there  will  be  no  union. 

In  lateral  anastomosis  a  draw-string  is  first  passed  as  in  Fig.  199, 
and  the  button  slipped  into  the  incision  and  held  with  forceps  while 
the  string  is  tightened  and  tied. 

In  end-to-end  anastomosis  the  cut  edge  of  the  gut  is  whipped  over 
by  a  continuous  silk  suture  which,  after  the  insertion  of  the  button, 
is  tightened,  and  tied  around  the  stem. 

Should  any  mucous  membrane  protrude  after  the  halves  of 
the  button  have  been  closed  on  each  other,  they  must  be  carefully 
buried  with  additional  Lembert  sutures.  When  perfect  apposition 
of  the  serous  surfaces  is  secured  by  the  button,  no  additional  sutur- 
ing is  necessary. 

The  number  of  accidents  attendant  upon  the  introduction  of  this 
metallic  body  into  the  intestine  is  already  very  considerable  ;  and  it 
should  only  be  used  in  the  rare  cases  of  shock  where  great  rapidity 
becomes  the  most  essential  consideration. 

Back  to  Back  Suture. 

In  some  cases  the  loss  of  tissue  in  the  gut  is  so  great  that  the  op- 
erator fears  to  close  the  opening  by  suture,  lest  stricture  should  re- 
sult, and  yet  hesitates  to  do  a  complete  resection. 

Under  such  circumstances  the  suture  shown  in  Figs.  200  and  201 
may  answer  a  very  useful  purpose.  By  it  the  calibre  is  preserved  to 
the  greatest  possible  extent. 

This  method  is  especially  applicable  to  ragged  ulcers  of  the  intes- 
tine, the  edges  of  which  must  be  freshened.  The  opening  in  the  bowel 
should  be  three  or  four  inches  long,  and  the  Czerny-Lembert  suture 
is  safest,  as  there  may  be  considerable  tension  from  within  the  bowel 
before  firm  union  has  had  time  to  occur. 

Lateral  Implantation. 

This  is  in  reality  a  modification  of  MaunselFs  operation,  espe- 
cially adapted  to  uniting  the  small  intestine  to  the  large  in  the  neigh- 


346 


SUEGERY   OF   THE   KECTUM   AND   PELVIS. 


Fig.  200. 
Elongated  wound  in  the  gut  ready  to  be  folded  together  and  sutured. 

/ 


Fig.  aoi. 
Suture  Completed. 


INTESTINAL    RESECTION    AND   ANASTOMOSIS. 
/ 


347 


Fig.  202. 
Lateral  Implantation.     First  Step. 


'borliood  of  the  caput  coli,  after  resection  of  a  part  or  the  whole  of 
the  latter. 

The  anastomosis  here  may  be  done  end  to  end  by  cutting  the  end 
•of  the  smaller  segment  obliquelj^  to  make  it  correspond  in  calibre 


Pig.  203. 
Lateral  Implantation.     Second  Step. 


348 


SURGERY   OF   THE   RECTUM   AND   PELVIS. 


Fig.  204. 
Lateral  Implantation.     Third  Step. 


Fig.  205. 
Lateral  Implantation  Completed. 


INTESTINAL    RESECTION    AND   ANASTOMOSIS.  349 

with  the  larger,  as  is  often  of  benefit  when  there  is  a  marked  differ- 
■ence  in  the  size  of  the  segments  to  be  united  ;  or  it  may  be  done 
by  Abbe's  method,  which,  however,  requires  more  time. 

As  will  be  seen  by  Figures  202,  203,  204  and  205,  the  technique 
differs  but  little  from  that  of  Maunsell.  Fig.  202  shows  the  four 
drawing  strings,  numbered  in  the  order  in  which  they  are  to  be  tied. 

The  remaining  steps  are  identical  with  those  in  Maunsell' s  opera- 
tion. 

Fig.  203  shows  three  of  the  draw-strings  tied  and  passed  out  of 
the  cut  end  of  the  large  intestine,  while  the  fourth  is  about  to  be  tied 
and  then  carried  into  the  lumen  of  the  larger  bowel  between  the 
approximated  cut  edges  with  a  pair  of  forceps. 


CHAPTER  XX. 

CONSTIPATION  — FECAL     IMPACTION  —  PRURITUS  —  WOUNDS    ANI> 
FOREIGN   BODIES— NEURALGIA— SPASM   OF   THE    SPHINCTER. 

It  may  be  stated  as  a  general  rule  that  a  person  in  health  should 
have  one  daily  evacuation  from  the  bowels.  And  yet  to  this  rule 
there  are  many  exceptions  ;  for  some  people  in  perfect  health  go  to 
the  closet  both  night  and  morning,  and  others  but  once  in  forty- 
eight  hours,  three  days,  or  even  longer. 

Usually  at  a  certain  hour  in  the  twenty-four,  which  in  a  healthy 
person  is  fixed  and  invariable,  there  is  felt  a  desire  to  relieve  the 
bowels,  caused  by  a  physiological  process  carried  on  without  the 
knowledge  or  will  of  the  individual. 

Simply  from  the  force  of  a  habit  which  has  existed  for  years,  or 
from  the  effects  of  a  routine  mode  of  life — such  as  a  morning  meal 
taken  at  the  same  hour  every  day,  and  composed  of  the  same  articles 
of  food — the  muscular  layers  of  the  bowel  begin  a  rhythmic  contrac- 
tion which  forces  the  solid  fecal  residue  contained  in  the  sigmoid 
flexure  down  into  the  rectum,  where  its  mere  presence  excites  a  de- 
sire for  its  removal. 

Thus  far  the  process  of  defecation  is  purely  involuntarj^  ;  but  be- 
yond this  it  is  under  the  control  of  the  individual,  and  he  may 
yield  to  this  call  of  nature  or  disregard  it  and  pay  the  penalty.  A 
sensible  person,  having  regard  to  his  health  and  comfort,  will 
promptly  regard  the  hint  that  nature  is  ready  to  do  her  part  in  un- 
loading the  economy  of  its  refuse,  and  will  allow  no  light  matter  to 
interfere  with  the  regular,  daily  morning  evacuation  of  the  bowels. 

Should  the  individual  resist  this  hint  of  nature,  and  by  a  volun- 
tary exercise  of  tlie  will  prevent  the  escape  of  faeces,  the  desire  soon. 


CONSTIPATION — PRURITUS.  351 

passes  off ;  the  mass  is  returned  by  reverse  peristalsis  to  the  sigmoid 
flexure,  there  to  remain  till  nature  repeats  the  call,  or  till  a  succes- 
sion of  bad  symptoms  forces  the  patient  to  seek  relief  in  medicine. 

It  is  a  curious  question  how  long  a  person  may  go  without  any 
evacuation  of  the  bowels  and  without  seeming  to  suffer  any  very 
severe  consequences  ;  and  remarkable  cases  are  on  record,  usually  in 
women  in  the  lower  walks  of  life.  Some  of  the  following  cases, 
taken  from  Johnston,  are  almost  incredible,  but  those  in  which  the 
time  is  reckoned  by  months  may  easily  be  believed. 

Thus  :  In  the  American  Journal  of  the  Medical  Sciences,  1846, 
page  260,  there  is  a  case  reported  lasting  three  months  and  twenty- 
two  days  ;  in  the  "  Dictionnaire  des  Sciences  medicales,"  t.  vi.,  page 
257,  one  b}^  Renandin  of  four  months  ;  in  the  American  Journal  of 
the  Medical  Sciences,  October,  1874,  page  440,  one  by  Strong  of  eight 
months  and  sixteen  days ;  in  the  Bulletin  des  Sciences  medicales,  t. 
X.,  page  74,  one  by  Valentin  of  nine  months  ;  in  the  London  Medi- 
cal Gazette,  1843,  vol.  xi.,  page  245,  Staniland  reports  one  of  seven 
months  ;  in  the  "Dublin  Hospital  Reports,"  vol.  iv.,  page  303,  there 
is  one  of  eight  months  ;  Inman,  in  the  Half-  Yearly  Abstract  of  Medi- 
cal Science,  vol.  xxxi.,  page  275,  reports  one  of  two  years  ;  Devilliers, 
Journal  de  Medecine,  1756,  t.  iv.,  page  257,  reports  another  of  two 
years  ;  Chalmers'  Medical  Gazette,  1843,  vol.  xxi.,  page  20,  reports 
one  of  three  years  ;  and,  finally,  in  the  reports  of  the  Philadelphia 
Medical  Museum,  1805,  vol.  i.,  page  304,  there  is  one  reported  in 
which  the  patient  went  fourteen  years  without  an  evacuation  of  the 
bowels. 

The  causes  of  constipation  are  manifold.  The  first  and  simplest 
is  the  one  already  hinted  at — ignorance  and  carelessness  on  the  part 
of  the  individual.  Women  suffer  more  than  men,  because  a  false 
sense  of  modesty  leads  them  oftener  to  neglect  the  call  of  nature,  and 
because  their  habits  of  indoor  life  and  lack  of  exercise  lessen  the 
force  of  the  peristaltic  movements  of  the  bowel.  Again,  the  con- 
dition of  pregnancy  leads  often  to  a  state  of  constipation  while  it 
lasts  ;  and  frequent  repetitions  of  it  are  apt  to  render  this  chronic 
from  a  loss  of  muscular  tone  in  the  parts  concerned  in  defecation. 

The  habits  of  life  and  the  occupation  of  the  individual  are  often 
the  cause  of  his  trouble.     Brain  work  at  the  expense  of  physical  ex- 


352  SURGERY    OF   THE   RECTUM    AND    PELVIS. 

ercise  ;  over-eating  and  physical  inertia  ;  tlie  necessity  for  sitting  long 
in  one  posture  (tailors,  shoemakers,  etc.),  improper  nutrition,  or  lack 
of  nutrition — anything  which  lessens  the  physical  powers— may  all 
fairly  be  put  down  as  causes  of  this  condition. 

For  the  same  reason  old  people  and  infants  are  more  apt  to  suffer 
than  the  young  and  middle-aged,  because  of  the  general  lowering  of 
Yitality  and  the  absence  of  muscular  strength. 

Another  common  cause  is  the  habit  of  using  laxatives,  and  this 
acts  as  does  the  habit  of  constantly  whipping  a  horse — he  soon  ex- 
pects to  be  whipped  before  he  goes.  Many  other  causes  might  be 
dwelt  upon  at  length — the  use  of  drugs,  especially  opium  and  per- 
haps also  tea  ;  the  loss  of  fluids  from  the  body  by  certain  exhaustive 
diseases  ;  the  lack  of  sufficient  fluid  with  the  food  ;  and  the  use  of 
food  of  too  concentrated  a  quality  and  containing  too  little  refuse 
matter. 

Constipation  is  often  also  a  symptom  of  gastric  or  intestinal  indi- 
gestion, both  in  children  and  adults.  It  is  also  an  accompaniment  of 
spinal  disease,  leading  to  paralysis,  and  in  this  class  of  cases  is  often 
attended  by  prolapse  of  the  mucous  membrane  to  a  marked  degree, 
and  can  only  be  relieved  by  a  mechanical  emptying  of  the  lower 
Ibowel  by  the  nurse  with  fingers  or  spoon  as  often  as  an  accumulation 
takes  place. 

Intestinal  obstruction  from  this  cause  may  be  the  immediate  cause 
of  death,  as  I  have  seen  in  my  own  practice. 

A  cause  of  constipation  of  more  especial  interest  to  the  surgeon  is 
the  existence  of  any  affection  of  the  rectum  or  anus  which  renders 
the  act  of  defecation  painful — so  painful  that  an  infant  will  cry  when 
placed  on  the  pan,  and  will  exert  all  its  powers  to  prevent  a  passage, 
and  an  adult  will  postpone  the  act  as  long  as  possible. 

A  physician  who  was  under  my  care  some  years  ago  for  fibroid 
polypi  of  the  rectum,  assured  me  that  the  act  of  defecation  caused 
him  such  acute  suffering  that  he  always  avoided  it  as  long  as  he  pos- 
sibly could  without  being  positively  sick ;  and  then,  when  he  could 
postpone  it  no  longer,  was  in  the  habit  of  administering  chloroform 
to  himself  on  the  closet  to  deaden  the  pain. 

The  most  common  of  these  affections  which  tend  directly  to  cause 
•constipation  on  account  of  the  suffering  they  give  rise  to  in  defeca- 


CONSTIPATION — PEURITUS.  353 

tion  are  piles,  fissures,  ulcers,  and  fistula.  One  otlier  cause  which 
must  never  be  forgotten  in  an  obstinate  case  is  the  possibility  that 
the  bowel  may  be  congeni tally  malformed  in  such  a  way  as  to  render 
easy  and  complete  evacuation  impossible.  There  maybe  a  congenital 
narrowing  of  the  intestine  two  or  three  inches  above  the  anus,  which, 
as  life  advances,  shall  make  itself  more  and  more  apparent  in  the 
way  of  difficult  evacuation.  There  is  also  a  spasmodic  contraction  of 
the  sphincter  muscle  which  may  be  due  to  a  congenital  narrowness  or 
may  be  acquired  in  adult  life,  and  which  will  render  defecation  so 
painful  that  obstinate  constipation  is  but  the  natural  consequence. 
This  is  sometimes  the  result  of  fissure,  and  at  others  a  purely  nervous 
affection  without  fissure,  and  as  far  as  my  knowledge  goes,  it  consti- 
tutes the  only  sound  indication  for  the  now  too  popular  operation  of 
stretching  the  sphincter. 

A  painful  affection  of  this  kind  may  very  soon  establish  a  vicious 
circle  which  it  may  be  difficult  to  break.  First  the  pain  causes  a  vol- 
untary constipation  ;  then  the  passage  of  hard,  large  masses  of  fseces 
does  mechanical  injury  to  the  diseased  parts  and  renders  them  worse  ; 
and  in  this  circle  the  patient  travels  till  complete  loss  of  health  and 
serious  disease  is  the  result. 

Constipation  is  not  only  a  symptom  of  disease,  as  in  the  cases 
enumerated,  but  is  also  attended  by  its  own  train  of  consequences. 
When  long-continued  it  leads  to  certain  changes  in  the  bowel  and 
adjacent  parts.  It  is  thus  the  most  frequent  cause  of  piles,  fissures, 
ulceration,  and  abscess.  Prolapse  of  the  bowel  is  often  caused  by 
this  condition,  and  cases  of  actual  rupture  from  straining,  with  fatal 
consequences,  have  been  reported. 

In  addition  to  these  results,  which,  being  external,  necessarily 
attract  the  notice  of  the  sufferer,  other  changes  are  often  produced 
internally  of  which  he  or  she  may  be  entirely  unconscious.  The  nat- 
ural result  of  turning  the  large  bowel  into  a  reservoir  for  solid  fseces 
is  to  cause  dilatation  of  its  calibre  and  paralysis  of  its  walls.  In  this 
way  it  may  assume  vast  dimensions,  filling  the  entire  abdominal  cav- 
ity and  pressing  all  movable  organs  out  of  their  natural  position. 
The  amount  of  fecal  matter  which  may  accumulate  in  the  large 
intestine,  in  cases  of  chronic  constipation,  is  simply  enormous.  The 
whole  abdomen  may  be  practically  filled  with  it.     In  one  case  fifteen 

23 


354  SUKGERY   OF   THE   RECTUM   AND   PELVIS. 

quarts  of  semi-solid  faeces  were  removed  on  autopsy  ;  and  in  another 
the  weight  of  the  collection  found  in  the  bowel  was  twenty-six  pounds. 

The  following  case  from  Bristow  illustrates  not  only  the  changes 
which  constipation  may  cause  in  the  wall  of  the  bowel,  but  also  the 
fatal  termination  from  intestinal  obstruction. 

It  was  "  that  of  a  little  girl,  eight  years  old,  whom  I  saw  casually 
only  during  life,  and  of  whose  history  I  obtained,  after  her  death, 
some  not  very  perfect  details.  She  had  long  suffered  from  tendency 
to  constipation  ;  and  it  was  stated  that  she  had  occasionally  gone  as 
long  as  three  weeks  without  passing  an  evacuation. 

"At  the  time  of  her  admission  into  the  hospital  there  had  been  no 
relief  to  the  bowels  for  seven  weeks.  She  was  then  pale  and  thin, 
had  a  large,  tense  belly,  without  pain  or  tenderness,  a  clean  tongue, 
and  a  poor  appetite.  She  had  a  '  strumous '  look,  and  was  supposed, 
I  believe,  to  be  suffering  from  abdominal  tubercle. 

"She  became  gradually  more  and  more  emaciated  and  anxious- 
looking,  while  the  belly  grew  larger  and  more  tense.  She  never  had 
any  distinct  abdominal  tenderness,  but  suffered  at  times  from  colicky 
pains,  and  often  (especially  toward  the  close  of  life)  complained  that 
she  was  so  full  that  she  felt  as  if  she  would  burst.  During  the  last 
week  or  two  the  tongue  became  somewhat  foul,  and  she  had  frequent 
vomiting,  but  never  of  stercoraceous  matter.  She  passed  but  little 
urine,  and  that  was  high-colored  ;  she  sank  gradually  from  exhaus- 
tion, and  died  exactly  three  weeks  after  admission. 

"Amongst  other  kinds  of  treatment  adopted  was  the  use  of  purga- 
tive medicines  and  of  purgative  injections  ;  and  the  medical  man  in 
attendance  on  her  was  led  to  believe  that  they  had  acted.  There  is 
no  doubt,  however,  from  subsequent  inquiries,  as  well  as  from  what 
was  observed  after  death,  that  he  was  deceived. 

"At  the  post-mortem  examination  the  form  of  the  distended  intes- 
tines was  distinctly  impressed  on  the  tense  and  thin  abdominal  walls, 
and  on  opening  the  abdomen  the  enormously  enlarged  colon  was  at 
first  alone  visible. 

"The  distention  began  at  the  caecum  and  extended  to  within  two 
inches  of  the  anus,  where  it  ceased  abruptly.  In  the  greater  part  of 
its  extent  the  bowel  measured  from  nine  to  ten  and  a  half  inches  in 
circumference,  the  greatest  amount  of  distention  being  manifested  in 


CONSTIPATION — PRURITUS.  355 

the  sigmoid  flexure.  The  muscular  walls  were  hypertrophied  from 
the  ascending  colon  to  the  lower  end  of  the  sigmoid  flexure  ;  and  in 
the  latter  situation  (where  the  hypertrophy  was  greatest)  they  meas- 
ured one-eighth  inch  in  thickness.  The  mucous  membrane  seemed 
healthy  in  the  greater  part  of  its  extent,  but  it  presented  some  con- 
gestion here  and  there,  and  at  distant  intervals  large  patches  in 
which  there  were  groups  of  small,  circular,  shallow  ulcers. 

"The  bowel  contained  no  flatus,  but  was  completely  full  of  thick, 
semi-solid,  olive-green-colored  faeces.  These  were  more  solid  in  the 
rectum  than  elsewhere,  and  immediately  above  the  anus  formed  an 
indurated,  conical  lump.  The  small  intestines  were  also  considerably 
distended." 

The  treatment  of  chronic  constipation  is  by  no  means  a  simple- 
matter.  It  may  be  begun  with  a  purgative,  such  as  three  compound 
cathartic  pills,  for  the  sake  of  opening  the  way  for  future  treatment  ; 
but  here  the  administration  of  purgatives  should  end,  for  their  repe- 
tition is  calculated  to  do  harm  rather  than  good,  by  substituting  an 
occasional  over-action  for  the  daily  one  which  indicates  a  healthy 
state  of  the  intestinal  tract. 

The  following  suggestions  may  be  found  of  use  in  the  treatment 
of  this  condition,  which  is  one  that  must  be  overcome  at  the  com- 
mencement of  the  treatment  of  any  rectal  affections  with  which  it 
may  be  associated. 

Constipation  may  be  due  to  deficient  action  of  either  the  small  or 
the  large  intestine,  and  this  deficient  action  in  either  case  may  be  the 
result  either  of  deficient  secretion  or  deficient  nerve  power. 

Deficient  secretion  is  very  apt  to  be  associated  with  hepatic  dis- 
turbance, and  is  marked  by  dull  headache,  bad  taste  in  the  mouth, 
viscid  secretion  from  the  buccal  glands,  etc.  This  is  a  condition 
pretty  sure  to  be  aggravated  by  cathartics,  for  the  reason  that  the 
temporary  increase  in  secretion  which  they  cause  is  followed  by  a 
corresponding  decrease,  which  serves  only  to  make  the  patient  worse 
than  before. 

For  the  purpose  of  increasing  the  natural  secretion  of  the  small- 
intestine,  the  fruits  containing  citric  acid,  such  as  oranges  ;  and 
other  fruits,  as  figs  and  apples,  when  the  patient  can  digest  them, 
all  serve  a  good  purpose.     Water  is  also  an  excellent  remedy,  and 


356  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

two  tumblerfuls  of  it  taken  in  the  morning  will  often  be  very  bene- 
ficial. To  it  may  be  added  a  slight  saline,  which  decreases  its  capa- 
bility for  absorption  (3  ss.-O  i.)  and  therefore  increases  the  per- 
istalsis ;  and  the  addition  of  a  single  grain  of  quinine  is  said  to 
greatly  increase  the  effect.  This  treatment,  if  patiently  persisted  in 
for  a  few  weeks,  will  generally  be  followed  by  a  good  result. 

Deficient  innervation  will  be  found  in  old  people,  people  of  seden- 
tary habits,  and  those  who  have  little  exercise.  In  such  cases  water 
will  be  found  only  to  weaken  the  digestive  power,  unless  it  can  be 
combined  with  a  different  mode  of  life  and  abundance  of  out-door 
exercise.  Cold  bathing,  however,  cold  against  the  spine  and  abdo- 
men, plenty  of  exercise  in  the  open  air,  and  nux  vomica,  will  gener- 
ally be  found  to  give  relief. 

In  constipation  dependent  upon  the  large  intestine,  the  trouble 
will  generally  be  found  to  be  due  to  deficient  innervation  rather  than 
to  any  lack  in  the  secretion.  It  is  best  treated  by  keeping  the  rec- 
tum empty,  by  nux  vomica,  or  belladonna  in  doses  sufficient  to  cause 
dryness  of  the  throat,  and  by  electricity.  The  latter  should  be  in 
the  form  of  the  faradic  current,  one  pole  being  placed  over  the  spine 
and  the  other  passed  up  and  down  along  the  track  of  the  colon. 

Constipation  in  CMldren. 

Infantile  constipation  may  be  due,  as  pointed  out  by  Jacobi,  to 
the  disproportionate  length  of  the  sigmoid  fiexure.  In  children  it  is 
not  unusual  to  find  two,  or  even  three,  flexures  in  the  lower  part  of 
the  colon,  in  which  the  faeces  may  remain  until  they  become  hard  and 
friable ;  and  v^hen  such  an  anatomical  formation  is  associated  with 
a  deficiency  of  the  intestinal  secretion  a  very  obstinate  constipation, 
and  even  impaction,  may  result. 

The  usual  causes  of  constipation  in  children  are : 

First.  Improper  feeding.  An  excess  of  starch,  or  of  any  article 
which  overtaxes  the  digestive  power,  may  burden  the  alimentary 
canal  with  a  large,  undigested  residue,  and  thus  set  up  a  costive 
habit. 

By  such  means  a  mild  catarrh  of  the  intestinal  mucous  membrane 
is  excited  and  maintained.     There  is  an  excess  of  mucus,  and  the 


CONSTIPATION — PKURITUS.  357 

fecal  masses,  rendered  slimy  by  the  secretion,  afford  no  sufficient 
resistance  to  the  muscular  contractions  of  the  bowels,  so  that  this 
slips  ineffectually  over  their  surface. 

Second.  Dryness  of  the  stools.  Even  in  the  youngest  infants  the 
evacuations  may  sometimes  be  seen  to  consist  of  small,  hard,  round 
balls,  like  sheep's  dung.  This  form  of  costiveness  is  generally  due 
to  insufficiency  of  fluid  taken.  The  food  is  made  too  thick,  or  the 
needs  of  the  system  in  the  matter  of  water  are  overlooked. 

But  whether  the  constipation  be  due  originally  to  excess  of  mu- 
cus or  deficiency  of  fluid,  it  cannot  continue  long  without  affecting 
injuriously  the  peristaltic  movement  of  the  bowels.  As  the  colon 
grows  accustomed  to  being  overloaded,  the  intestinal  contents  can 
no  longer  exert  a  sufficiently  stimulating  influence  upon  the  lining 
membrane,  and  the  muscular  contractions  begin  to  flag. 

If  the  infant  be  badly  nourished,  this  languor  of  muscular  con- 
traction may  be  aggravated  by  actual  weakness  of  the  muscular 
walls  ;  and  as,  under  these  conditions,  the  bowel  is  apt  to  be  overdis- 
tended  by  accumulation  of  its  fecal  contents,  the  expulsive  force  at 
the  disposal  of  the  patient  is  seriously  impaired.  Constipation  due 
to  the  above-mentioned  causes  is  often  made  more  serious  by  the  in- 
fant's own  efforts  to  delay  relief. 

A  baby  whose  motions  are  habitually  costive  knows  well  the 
suffering  which  undue  distention  of  the  sphincter  w^ill  entail,  and 
often  yields  to  the  desire  to  go  to  stool  only  when  it  is  no  longer  pos- 
sible to  resist.  The  pain  is  sometimes  aggravated  by  the  formation 
of  little  fissures,  and  the  violent  action  of  the  sphincter,  set  up  by 
their  presence,  forms  an  additional  impediment  to  free  evacuation. 

The  form  of  constipation  due  to  mild  intestinal  catarrh  is  com- 
mon enough  in  young  infants.  This  is  owing,  no  doubt,  in  great 
measure  to  overabundant  feeding  with  starchy  matters,  or  to  the 
giving  of  cow's  milk  without  taking  due  precautions  to  insure  a  fine 
division  of  the  curd. 

When  constipation  is  due  to  this  cause,  our  first  care  must  be  to 
protect  the  child's  sensitive  body  so  as  to  put  a  stop  to  the  series  of 
catarrhs.  To  do  this  it  will  not  be  sufficient  to  swathe  the  belly  in 
flannel.  The  legs  and  thighs  must  also  be  covered,  for  so  long  as  a 
square  inch  of  surface  is  left  bare  the  protection  of  the  child  is  in- 


3S8  "  SURGEKY   OF   THE   RECTUM   AND   PELVIS. 

complete.  The  infant's  diet  must  next  be  regulated  with  due  regard 
to  its  powers  of  digestion.  Excess  of  starch  must  be  corrected,  and 
it  is  best  to  have  recourse  to  one  of  the  malted  foods.  A  certain 
variety  in  the  diet  is  of  importance  in  all  cases  where  the  digestive 
power  is  temporarily  impaired. 

In  addition  to  the  regulation  of  diet  and  clothing,  the  bowels 
should  be  regularly  stimulated  by  manipulation.  The  sluggishness 
of  peristaltic  action  maybe  very  materially  quickened  by  judiciously 
applied  frictions. 

The  nurse  should  be  directed  to  rub  the  child's  belly  every  morn- 
ing after  the  bath.  She  should  use  the  palm  of  the  hand  and  ball  of 
the  thumb,  and,  pressing  gently  down  upon  the  right  side  of  the  ab- 
domen, carry  the  hand  slowly  round  in  a  circular  direction,  follow- 
ing the  course  of  the  colon.  The  frictions  may  be  continued  for  five 
minutes.  In  obstinate  cases  the  child  may  be  placed  upon  the  bed, 
and  the  bowels  gently  kneaded  with  the  thumbs  placed  side  by  side, 
the  movements  following  the  course  of  the  colon. 

In  addition  to  the  above-mentioned  general  treatment,  more 
special  measures  may  be  necessary.  These  may  be  divided  into  sup- 
positories and  enemata,  and  medicines  given  by  the  mouth.  The 
time-honored  piece  of  castile  soap  for  a  suppository  is  recommended, 
and  the  now  popular  enema  of  thirty  or  forty  drops  of  pure  glycerin. 

Large  enemata  of  soap  and  water  should  be  used  only  rarely,  as 
great  dilatation  of  the  rectum  and  permanent  loss  of  muscular  tone 
are  very  apt  to  follow  their  continued  use. 

Treatment. 

For  the  permanent  cure  of  habitual  constipation,  remedies  given 
by  the  mouth  are  greatly  to  be  preferred.  The  aim  should  be  to  find 
the  smallest  dose  which  will  awaken  a  normal  degree  of  peristalsis, 
and  to  give  this  dose  regularly  so  as  to  excite  a  habit  of  daily  evacu- 
ation. The  daily  dose  is  most  efficient  when  combined  with  a  remedy 
which  tends  to  give  tone  to  the  muscular  coat  of  the  bowel.  For  this 
purpose  a  useful  draught  is  composed  of  half  a  drop  of  tincture  of 
nux  vomica,  combined  with  ten  drops  of  tincture  of  belladonna  and 
twenty  of  infusion  of  senna,  made  up  to  a  fiuidrachm  with  infusion 


CONSTIPATION — PRUKITUS.  359 

of  calumba.  This  should  be  given  at  first  tliree  times  a  day  before 
food,  and  subsequently  reduced  to  twice  and  then  to  once  daily. 
The  liquid  extract  of  cascara  is  useful  in  many  cases,  especially 
when  combined  with  tincture  of  belladonna.  Twenty,  thirty,  or 
more  drops  of  cascara  extract,  with  ten  of  tincture  of  belladonna, 
may  be  given  with  a  few  drops  of  glycerin  every  night. 

When  the  motions  are  drier  than  normal,  a  saline  may  be  given 
in  addition  to  the  liquid  already  recommended  to  be  added  to  the 
diet.  The  saline  may  be  combined  with  small  doses  of  nux  vomica 
and  quinine.  For  a  baby  of  five  or  six  months,  five  to  ten  grains  of 
sulphate  of  sodium  may  be  given  with  a  quarter  of  a  grain  of  quinine, 
half  a  drop  of  tincture  of  nux  vomica,  and  a  minim  of  aromatic  sul- 
phuric acid,  in  a  teaspoon ful  of  water,  three  times  a  day  before  food. 
If  the  remedy  has  been  well  chosen,  its  quantity  may  soon  be  dimin- 
ished, and  finally  it  may  be  discontinued. 

An  adult  patient  should,  first  of  all,  be  instructed  to  have  a  reg- 
Tilar  time  for  the  daily  evacuation,  and  the  best  time  for  this  purpose 
is  immediately  after  breakfast.  The  time  being  fixed,  the  patient  is 
to  go  to  the  closet  whether  the  desire  for  a  passage  be  present  or  not, 
and  pass  a  certain  time  upon  the  commode.  I  generally  recommend 
the  time  immediately  after  the  morning  meal  for  this  purpose,  be- 
cause the  breakfast  itself  often  acts  as  a  stimulant  to  this  function, 
•especially  in  those  in  the  habit  of  taking  a  morning  cup  of  coffee. 

If  the  patient  be  a  man  in  the  habit  of  smoking,  the  first  few 
whiffs  of  smoke  often  act  in  the  same  way  ;  and  there  are  many  men 
to  whom  the  morning  cigar  or  cigarette  is  an  essential  to  the  daily 
evacuation.  In  such  a  case  it  must  be  a  very  decided  opponent  of 
the  weed  who  would  object  to  its  continuance  in  moderation. 

If  the  plain  cold  water  taken  in  the  morning  has  no  effect,  the 
mineral  waters  may  be  tried  in  its  place  with  great  advantage,  and 
the  patient  may  select  the  one  most  agreeable  to  the  taste  and  which 
most  effectually  accomplishes  the  desired  end.  The  morning  meal 
may  consist  of  whatever  the  patient  most  desires,  but  a  dish  of  oat- 
meal or  coarse  cracked  wheat  and  milk  should  always  be  an  essen- 
tial part  of  it. 

I  have  almost  always  found  that  where  perfect  regularity  in  the 
•daily  life  with  regard  to  eating  and  exercise  can  be  established,  the 


360  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

function  of  defecation  will  also  be  performed  regularly,  provided  the 
diet  be  of  tlie  proper  quality.  To  have  a  copious,  well-formed  evac- 
uation, it  is  not  at  all  necessary  that  the  diet  should  be  composed  of 
substances  which  leave  a  considerable  quantity  of  waste,  such  as 
the  coarser  grains  and  vegetables.  On  the  contrary  I  much  prefer 
the  most  nutritious  food  that  can  be  taken  and  of  the  best  quality, 
mixed  with  a  free  supply  of  milk. 

In  women  a  certain  regulated  amount  of  daily  out-door  exercise 
should  be  insisted  upon,  in  spite  of  all  excuses  and  professions  of 
disability.  If  necessary,  this  may  be  small  at  first,  and  gradually 
increased  ;  and  in  a  woman  who  has  lost  the  habit  and  perhaps  al- 
most the  power  of  walking,  considerable  tact  and  firmness  on  the 
part  of  the  physician  may  be  required  to  carry  out  this  part  of  the 
treatment,  but  it  will  be  found  to  be  care  well  spent. 

In  addition  to  these  dietetic  and  hygienic  rules,  certain  medica- 
tion may  and  often  will  be  found  necessary.  This  should  be  of  the 
mildest  possible  kind  which  will  accomplish  the  object.  A  pill 
which  I  have  found  to  act  very  effectually  and  pleasantly  under 
these  circumstances  is  made  after  the  following  formula  : 

^  Pulv.  aloes  soc gr.  iss. 

Ext.  nucis  vom gr.  ss. 

Ext.  belladonnse - gr.  -I 

M. 

One  of  these  should  be  taken  at  bedtime,  and  will  generally  be 
followed  by  an  easy  passage  on  the  following  morning.  If  this  does 
not  work  satisfactorily,  various  other  remedies  may  be  substituted, 
amongst  the  best  of  which  is  the  compound  licorice  powder,  the  rhu- 
barb and  soda  mixture,  or  the  dinner  pill ;  the  object  being  to  find 
one  among  the  many  laxative  preparations  which,  without  causing 
pain  or  diarrhoea,  will  give  an  easy  and  natural  evacuation  of  the 
bowels  once  every  da}'. 

The  use  of  enemata  for  chronic  constipation  should  not  be  com- 
menced till  all  other  means  have  failed,  for  the  reason  that  when 
once  the  bowel  has  become  accustomed  to  this  form  of  stimulus  it 
will  be  found  very  difficult  to  discontinue  its  use.  In  some  cases, 
however,  their  employment  may  be  a  necessity,  and  they  are  always 


COXSTIPATIOX — PKUKITUS.  361 

milcli  less  harmful  than  purgatives.  Instead  of  the  ordinary  enema 
of  soap  and  water,  the  introduction  of  a  harmless  foreign  body  into 
the  rectum  will  sometimes  excite  peristalsis.  Small  fragments  of 
soap  or  of  candles  are  preferred  by  many  for  this  purpose  to  fluid 
injections. 

Much  evil  is  being  done  by  the  practice  now  quite  common 
among  the  laity  of  washing  out  the  lower  bowel  with  large  quanti- 
ties of  hot  water  daily. 

Im/pactlon  of  Fceces. 

The  impaction  of  faeces  may  be  due  to  several  causes,  but  is  most 
generally  a  symptom  either  of  intestinal  atony  in  old  people,  or  of 
some  paralytic  affection,  such  as  locomotor  ataxia.  It  not  infre- 
quently occurs  in  women  as  a  result  of  the  entire  neglect  of  the  func- 
tion of  defecation,  for  which  tlie}^  are  perhaps  unjustly  celebrated  ; 
and  it  may  follow  a  partial  paralysis  of  the  rectum  from  the  long- 
continued  use  of  large  enemata,  or  the  pressure  of  the  foetal  head  in 
childbirth. 

It  may  also  result  as  a  consequence  of  a  painful  affection,  such- 
as  a  fissure,  which  renders  each  act  of  defecation  an  agony  to  be 
avoided  by  every  possible  means.  The  disease  is  generally  one  of  old 
people,  of  hysterical  girls,  and  of  careless  women  ;  but  it  has  been 
seen  in  children,  and,  as  a  result  of  imjoroper  diet,  may  occasionally 
be  encountered  in  young  and  healthy  men. 

Intestinal  concretions  may  be  composed  entirel}"  of  hardened  and 
stratified  or  clayey  masses  of  faeces,  or  they  may  contain  within 
them  as  a  nucleus  a  biliary  calculus,  or  indigestible  substances  which 
have  been  hastily  swallowed,  such  as  peach  pits,  cherry  stones,  etc. 
Molliere  calls  attention  to  the  presence  of  magnesia,  which  favors  the 
aggregation  of  faecal  matters,  and  which  also  may  act  as  the  nucleus 
of  a  scybalum  ;  and  the  frequenc}^  of  impaction  during  the  famine  in 
^Ireland  in  1846,  when  potatoes,  and  those  of  a  very  poor  quality, 
were  the  only  article  of  diet,  is  a  well-known  historical  fact. 

In  Scotland,  where  oatmeal  is  a  favorite  article  of  diet,  fecal  ac- 
cumulations are  said  to  be  of  frequent  occurrence.  Certain  other 
drugs  besides  magnesia,  such  as  chalk,  sulphur,  and  powdered  cu- 
bebs,  have  been  blamed  as  the  cause  of  intestinal  concretions.     In- 


362  SURGERY    OF   THE   RECTUM    AND   PELVIS. 

testinal  calculi  have  been  seen  which  were  composed  of  pure  choles- 
terin,  or  of  a  biliary  calculus  coated  with  cholesterin. 

The  usual  location  of  a  mass  of  impacted  faeces  is  the  rectal 
pouch,  but  it  may  be  situated  anywhere  between  the  caecum  and  this 
point.  The  symptoms  to  which  it  gives  rise  are  generally  suffi- 
ciently well  marked  to  enable  the  practitioner  to  reach  a  correct  diag- 
nosis if  he  be  on  his  guard.  The  pains  which  it  causes  will  gener- 
ally be  obscure  and  may  be  located  anywhere  in  the  abdomen  or  in 
the  lower  extremities  ;  and  the  signs  of  disturbance  in  digestion  are 
not  in  themselves  sufficiently  marked  for  diagnosis,  but  the  one 
symptom  which  is  characteristic  is  diarrhoea. 

Just  as  the  practitioner  has  to  learn  that  incontinence  of  urine 
may  be  a  sign  of  a  distended  and  not  an  empty  bladder,  so  he  may 
have  to  learn  by  a  disagreeable  error  in  diagnosis  that  a  diarrhoea  is 
sometimes  a  result  of  an  overfilled  and  obstructed  rectum. 

This  diarrhoea  is  peculiarly  fetid  in  character,  and  the  matters 
discharged  may  be  entirely  free  from  feeces  and  consist  entirely  of 
mucus.  In  some  cases  there  may  be  an  approach  to  a  daily  natural 
evacuation.  The  act  of  defecation  is  always  attended  by  straining 
and  pain  as  the  fecal  ball  is  pressed  down  against  the  perineum  and 
rises  again  when  the  muscular  effort  ceases.  Besides  this  we  see 
coldness  and  swelling  of  the  feet  from  pressure  on  the  pelvic  and  ab- 
dominal veins  ;  varicose  veins  in  the  legs  ;  varicocele  ;  shooting  pains 
in  the  legs,  groins,  and  loins  from  pressure  on  the  sacral  nerves  ; 
seminal  emissions,  jaundice,  and  albuminuria  from  pressure.  One  of 
my  curious  cases  was  that  of  a  fine,  healthy  boy  of  eleven  years, 
brought  to  me  for  incontinence  of  faeces.  There  was  no  trouble  with 
the  bladder,  but  at  any  time,  in  school  or  in  bed,  the  boy  was  apt  to 
have  an  involuntary  passage  from  the  bowels.  Making  a  digital  ex- 
amination to  test  the  contractile  power  of  the  sphincter,  I  found  it 
to  be  perfect,  and  not  until  I  had  found  a  large,  old  fecal  impaction 
did  the  cause  of  the  overflow  become  clear.  An  enema  and  a  purga- 
tive cured  him. 

Of  course  errors  in  diagnosis  are  easy  in  such  a  condition  as  this, 
and  a  mass  of  faeces  in  the  colon  may  be  mistaken  for  any  and  every 
sort  of  tumor  in  the  pelvis  or  abdomen.  Liver,  spleen,  stomach, 
uterus,   and  ovaries  have  again  and  again  been  supposed  diseased 


CONSTIPATION  —  PRURITUS.  363 

in  these  cases,  when  a  simple  digital  examination  of  the  rectum,  or, 
in  women,  even  of  the  vagina,  could  not  fail  to  make  the  diagnosis 
clear. 

Unfortunately  for  diagnosis,  the  general  practitioner  is  not  fond 
of  making  rectal  examinations,  and  these  cases  are  not  infrequently 
treated  with  bismuth  and  opium  as  a  consequence. 

Treatment  of  Impaction. 

The  treatment  of  impaction  is  simple,  and  consists  first  of  all  in 
the  entire  removal  of  the  mass.  In  cases  of  paralysis,  where  the 
accumulation  has  not  been  allowed  to  reach  any  very  great  amount, 
and  the  scybala  are  small  and  not  very  hard,  this  may  sometimes  be 
accomplished  by  the  use  of  injections  with  a  long  tube  and  the 
assistance  of  the  finger  of  the  operator. 

In  women  very  effectual  aid  may  be  rendered  under  similar  con- 
ditions by  pressure  from  the  vagina,  by  which  small  masses  may  be 
extruded  one  after  another,  each  with  a  certain  amount  of  pain,  but 
without  laceration  of  the  mucous  membrane  at  the  anus.  This  plan 
of  treatment  will  often  constitute  one  of  the  regular  duties  of  the 
attendant  upon  a  case  of  paralysis — a  disagreeable  duty  which  must 
be  attended  to  at  certain  regular  intervals. 

In  cases  of  longer  standing,  however,  these  means  may  be 
entirely  inadequate,  and  all  injections,  no  matter  what  their  sup- 
posed solvent  virtues,  will  be  of  no  avail  even  if  they  are  not  at  once 
ejected.  In  such  cases  the  operation  of  breaking  up  and  removing 
the  mass  must  be  begun  by  the  administration  of  ether  and  dilata- 
tion of  the  sphincter.  This  accomplished,  the  mass  may  be  attacked 
with  the  lingers,  an  iron  spoon,  a  pair  of  lithotomy  forceps,  or 
scoop,  and  removed  piece  by  piece.  When  this  has  been  done,  an 
injection  may  be  administered  through  the  long  tube  and  more 
matter  will  generally  come  down  from  the  sigmoid  flexure.  The 
impacted  mass  is  often  as  large  as  the  fist,  and  sometimes  as  a  foetal 
head,  and  the  amount  in  the  sigmoid  flexure  and  colon  may  be 
much  greater,  though  not  as  hard,  so  that  at  a  single  sitting  an 
enormous  amount  may  be  removed. 

After  such  an  operation  as  this  the  patient  must  be  treated  by 


364  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

injections  and  a  daily  laxative,  as  described  in  speaking  of  constipa- 
tion, till  the  overdistended  rectum  has  recovered  its  tone.  This  may 
require  a  considerable  time. 

Pruritus. 

Pruritus  ani — itching  at  the  anus — is  generally  a  symptom  of 
some  other  disease,  such  as  hemorrhoids  or  eczema,  but  it  is  often 
present  in  a  marked  degree  when  no  cause  for  its  existence  can  be 
discovered.  It  is  an  exceedingly  painful  and  annoying  affection, 
and  one  which  will  often  tax  the  powers  of  the  surgeon  to  the  utmost 
for  its  cure. 

,  It  is  met  with  in  both  men  and  women,  and  seems  to  be  depend- 
ent upon  no  particular  general  state,  being  found  in  rich  and  poor, 
the  overfed  and  underfed,  the  professional  man  of  nervous  constitu- 
tion and  the  laborer  alike. 

The  disease  is  marked  by  an  itching  at  the  anus  which  is  more  or 
less  constant,  but  is  generally  worse  after  the  sufferer  has  become 
warm  in  bed  at  night.  The  itching  causes  an  attempt  at  relief  by 
scratching,  and  the  scratching,  though  it  may  be  controlled  during 
the  day,  is  generally  practised  unconsciously  during  sleep  to  an 
extent  which  causes  laceration  of  the  skin.  The  itching  in  bad 
cases,  even  when  constant,  is  marked  by  exacerbations  and  remis- 
sions, and  may  cause  an  amount  of  suffering  which  is  simply  un- 
bearable. 

The  disease  is  attended  by  certain  changes  in  the  appearance  of 
the  parts.  The  skin  becomes  thickened  and  parchment-like  (Fig. 
206),  or  else  eczematous  and  moist  from  exudation.  It  may  be  red 
from  the  scratching,  or  there  may  be  quite  a  characteristic  loss  of 
the  natural  pigment  of  the  anus.  In  the  latter  case  the  skin  becomes 
of  a  dull  whitish  color,  and  this  will  oftener  be  noticed  where  the 
disease  is  of  long  standing  and  severe. 

The  exudation  may  be  very  marked  where  the  itching  is  slight, 
and  may  be  attributed  by  the  patient  to  trouble  within  the  rectum 
instead  of  to  its  real  source.  Associated  with  the  changes  in  the 
skin  it  is  not  at  all  uncommon  to  find  one  or  several  fissures. 


CONSTIPATION — PPwURITUS.  365 

Causes. 

The  cause  of  pruritus  ma.j  sometimes  be  easily  discoverable,  and 
in  such  cases  a  cure  rapidly  follows  its  removal.  For  example, 
pruritus  is  often  a  symptom  of  internal  hemorrhoids,  and  is  easily 
and  effectually  cured  by  their  removal.  Again,  it  is  often  a  symp- 
tom of  complication  of  a  fistula  with  a  small  external  opening,  such 
as  may  easily  be  overlooked  in  a  cursory  examination,  and  is  cured 
by  the  ordinary  operation  and  the  consequent  cessation  of  the  dis- 
charge upon  which  it  depends. 

It  is  often  dependent  upon  the  presence  of  the  oxyuris  vermicu- 
laris  in  the  rectum,  and  in  every  case  these  should  be  carefully 
looked  for.  If  they  are  present  they  may  generally  be  seen  like 
small  pieces  of  white  thread  between  the  radiating  folds  at  the  mar- 
gin of  the  anus,  especiallj^  at  night  when  the  itching  begins.  They 
may  generally  be  eradicated  by  certain  simple  measures,  the  best 


Fig.  206. 
Thickened  Condition  of  the  Skin  in  Pruritus. 

known  of  which  is  an  enema  of  lime  water,  or  of  carbolic  acid,  3  i.  ; 
glycerin,  |  i.  ;  and  water,  |  vij.,  injected  after  each  passage.  Tur- 
pentine and  tincture  of  iron  may  be  used  for  the  same  purpose,  and 
are  both  very  elfectual  ;  but  the  parasites  are  much  more  easily 
removed  in  children  than  in  adults,  and  I  have  had  one  case  which 


366  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

was  exceedingly  intractable,  and  in  which  I  have  never  been  able  to 
keep  the  worms  from  returning  for  any  great  length  of  time.  A 
single  examination  should  never  be  considered  as  proof  of  the  ab- 
sence of  this  parasite  in  an  obstinate  case  of  pruritus. 

Instead  of  a  parasite  located  within  the  rectum,  pruritis  is  occa- 
sionally easily  accounted  for  by  the  presence  of  pediculi.  In  such  a 
case  the  diagnosis  and  cure  are  alike  easy. 

Again,  the  parasite  may  be  vegetable  instead  of  animal,  and  the 
itching  may  be  due  to  the  disease  known  as  eczema  marginatum. 
In  this  case  the  diagnosis  will  rest  upon  the  finding  of  the  spores, 
under  the  microscope,  in  the  epidermis  scraped  from  the  edge  of  the 
affected  spot  and  moistened  with  glycerin. 

The  most  effectual  remedy  for  this  condition  is  a  wash  of  equal 
parts  of  sulphurous  acid  and  water,  frequently  applied  with  a  soft 
cloth,  and  gradually  increased  in  strength,  if  necessarj^,  up  to  the 
pure  acid,  which  latter  is,  however,  generally  a  painful  application, 
and  one  which  will  readily  blister.  The  acid,  even  when  diluted  to  a 
considerable  extent,  will  blister  if  covered  with  a  cloth.  Strong 
tincture  of  iodine  applied  with  a  brush  is  also  an  effectual  remedy  in 
eradicating  the  plant. 

Pruritus  may  also  be  dependent  upon  other  skin  diseases,  among^ 
which  chronic  eczema  is  perhaps  the  most  common,  and  this  is  to  be 
i^reated  exactly  here  as  elsewhere  in  the  body,  first  by  general  meas- 
ures directed  to  the  constitutional  state,  and  second  by  local  applica- 
tion. 

The  congestion  and  the  thickening  of  the  skin  must  first  be 
remedied,  and  for  this  purpose  very  hot  water,  compound  tincture 
of  green  soap,  and,  if  necessary,  a  solution  of  caustic  potash  may  be 
applied.  The  water,  to  be  of  any  use,  must  be  as  hot  as  the  fingers 
can  bear,  and  should  be  applied  to  the  part  with  a  soft  cloth  and 
held  there  till  it  begins  to  cool.  This  may  be  repeated  half  a  dozen 
times,  but  all  rubbing  should  be  carefully  avoided  both  during  the 
application  and  in  drying  the  parts  after  it. 

This  is  a  favorite  remedy  with  most  dermatologists  ;  it  should  be 
used  just  before  going  to  bed,  and  is  often  in  itself  sufficient  to 
insure  a  good  night' s  sleep. 

If  there  be  thickening  of  the  skin  from  effusion,  a  stronger  appli- 


CONSTIPATION  —  PKURITUS.  367 

cation  than  hot  water  will  be  necessary  ;  and  for  this  the  com- 
pound tincture  of  green  soap  is  a  good  remedy,  or  the  solution  of 
potash  (gr.  v. -|  i.)  or  liquor  potassse  may  be  resorted  to  with  cau- 
tion. The  formula  for  the  compound  tincture  of  green  soap  is  the 
following : 

T},   Saponis  viridis, 
Olei  cadini, 

Alcohol aa  |  i. 

M. 

It  is  a  much  stronger  preparation  than  the  simple  green  soap,  and 
also  a  much  more  disagreeable  one,  but  it  is  very  effectual,  and 
should  be  well  rubbed  into  the  part  once  a  day.  These  remedies 
should  be  followed  at  once  by  soothing  ointments  or  lotions.  A 
good  ointment  is  the  ordinary  oxide  of  zinc  made  soft  and  applied 
gently,  and  one  which  is  j^retty  certain  to  allay  itching  is  that  made 
of  chloroform  ( 3  i.  -  |  i.).  This  soon  loses  its  power  by  the  evapora- 
tion of  the  chloroform,  and  should  on  this  account  be  kept  in 
a  wide-mouthed  glass  bottle,  tightly  corked,  and  should  be  fre- 
quently renewed.  Another  favorite  application,  and  one  which  is 
very  generally  effectual,  consists  in  a  lotion  of  carbolic  acid.  The 
formula  is : 

^   Acid,  carbolici |  ss. 

Glycerinse i  i. 

Aquse 1  iij. 

M. 

This  may  be  applied  at  night,  and  if  found  to  be  too  strong 
may  be  diluted  by  the  patient.  In  a  more  dilute  form  it  may 
also  be  continued  for  a  considerable  time  after  all  symptoms  have 
ceased. 

For  the  sake  of  those  who  have  never  encountered  an  obstinate 
case  of  this  disease,  but  who  are  pretty  sure  at  some  time  to  have 
both  knowledge  and  ingenuity  taxed  to  tlie  utmost,  I  will  give  one 
or  two  more  formulee  which  have  been  found  reliable  : 


368  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

I},   Sodse  biboratis 3  ij. 

Morph.  liydrochlor gr.  xvi. 

Acidi  liydrocyanici  dil ....    |  ss. 

Glycerinse §  ij. 

Aquse ad  |  viij. 

M. 

This  should  be  applied  to  the  part  four  or  five  times  in  the 
twenty-four  hours.  Dr.  Bulkley  has  also  recommended  the  follow- 
ing as  being  useful,  and  I  have  often  found  it  so  : 

^   Ungt.  picis 3  iij. 

"      bellad 3  ij. 

Tr.  aconit.  rad 3  ss. 

Zinci  oxidi 3  i. 

Ungt.  aquse  ros 3  iij. 

M. 

The  following  prescription  has  also  been  very  efficient  in  my 
hands.     I  am  indebted  for  it  to  Dr.  Salisbury  : 

B   Menthol 3  i. 

Simple  cerate §  ij. 

Oil  sweet  almonds 1  i. 

Carbolic  acid , 3  i. 

Pulv.  zinci  ox 3  ij. 

M.     Apply  morning,  noon,  and  night,  after  cleansing  the  parts. 

An  ointment  of  chloral  and  camphor,  a  drachm  of  each  to  the 
ounce,  is  also  at  times  effectual  in  allaying  itching. 

There  are  two  other  skin  diseases,  either  of  which  may  be  the 
cause  of  pruritus — herpes  and  erythema.  Herpes  at  the  margin  of 
the  anus  is  the  same  as  when  seen  on  the  lips.  In  tlie  latter  case  it 
heals  spontaneously,  in  the  former  a  dressing  may  be  necessary. 

This  may  consist  simply  of  a  dry  powder  such  as  zinc  or  bismuth, 
or  of  one  of  the  lotions  already  mentioned.  Erythema  will  be  found 
chiefly  in  fat  people,  where  it  is  due  to  contact  of  the  opposing  cu- 


CONSTIPATION — Pi:iIIiITUS.  369 

taneous  surfaces.  It  also  is  best  treated  bj^  the  application  of  dry- 
powders,  and  by  separating  the  opposed  surfaces  by  a  layer  of  dry 
sheet  lint  or  old  muslin. 

These  are  the  most  palpable,  and  perhaps  also  the  most  common, 
causes  of  pruritus,  but  there  are  many  cases  in  which  tlie  cause  is 
not  so  easily  discoverable,  because  it  is  a  constitutional  and  not  a 
local  one.  Where  no  local  cause  can  be  detected,  a  careful  inquiry 
must  be  instituted  with  regard  to  the  patient's  general  health  and 
habits.  If  chronic  constipation  be  present,  this  must  first  of  all  be 
overcome,  for  this  is  in  itself  an  efficient  cause  for  the  disease. 

Another  not  infrequent  cause  of  pruritus  is  derangement  in  the 
function  of  the  liver.  This  may  or  may  not  be  associated  with  con- 
stipation. It  must  be  treated  by  general  dietetic  measures,  the  dilute 
mineral  acids,  occasionally  by  doses  of  podophyllin,  active  out-of- 
door  exercise,  and  cold  and  friction  applied  to  the  hepatic  region. 

In  women  uterine  disorders  must  be  looked  for  and  cured  before 
very  much  will  be  accomplished  in  the  treatment  of  pruritus  ;  and 
the  urine  must  be  examined  for  sugar  in  obstinate  cases,  for  diabetes 
will  sometimes  give  rise  to  incurable  pruritus. 

In  case  none  of  these  causes  can  be  found  to  account  for  the  itch- 
ing, errors  of  diet  must  be  searched  for,  and  corrected  when  found. 
Anything  like  excess  in  smoking  or  in  alcoholic  drinks  will  keep  up 
the  disease,  and  in  men  these  habits  must  be  carefully  regulated,  if 
indulged  in  at  all. 

The  disease  will  sometimes  be  encountered  in  stout,  full-blooded 
persons  who  live  well  and  perhaps  incline  to  the  gout,  and  who  show 
no  other  signs  of  disorder.  In  such,  active  exercise  and  plainer  liv- 
ing, with  cold  bathing  of  the  part  at  night  and  morning,  and  the  use 
of  a  lotion  of  carbolic  acid,  will  often  effect  a  speedy  cure. 

On  the  other  hand,  the  disease  may  be  present  in  exactly  the  op- 
posite class  of  persons,  the  overworked  and  worried  professional  or 
business  man,  and  it  is  in  this  class  of  cases  alone,  where  the  itching 
seems  to  be  purely  a  nervous  symptom,  that  arsenic  is  indicated.  It 
may  be  combined  with  quinine  and  cod-liver  oil,  and  carried  up  to 
its  full  physiological  effect. 

In  old  cases,  which  resist  milder  measures,  I  have  worked  many 
cures  by  putting  the  patient  under  ether  and  applying  the  Paquelin 

24 


370  SUEGERY   OF  THE   RECTUM   AND   PELVIS. 

cautery  lightly  to  the  whole  afEected  surface.  Where  there  is  much 
induration,  a  few  stripes  may  be  made  entirely  through  the  derma  ; 
where  the  cause  is  an  old  eczema  without  much  infiltration,  the  entire 
surface  may  be  lightly  brushed  over  with  the  white  hot  cautery. 
When  the  burns  thus  made  have  healed,  the  patient  will  generally  be 
cured. 

In  this  way,  then,  the  physician  must  undertake  the  cure  of  a 
case  of  pruritus  ani ;  and  not  by  the  administration  of  any  single 
lotion  or  ointment  to  allay  the  itching,  which  is  but  the  symptom  of 
some  local  or  general  condition.  In  every  case  the  cause  must  be 
found  and  removed  if  success  in  the  treatment  is  to  be  gained. 

I  know  of  no  disease  of  the  rectum  or  anus  in  which  there  is  a 
better  chance  for  the  practitioner  to  show  his  general  knowledge  and 
skill.  If  a  case  be  undertaken  in  this  way,  and  the  treatment  be  in- 
telligently followed  by  both  doctor  and  patient,  a  cure  may  generally 
be  effected  ;  sometimes  in  a  very  few  days,  but  at  others  only  after 
prolonged  effort  and  many  discouragements.  The  prognosis  should, 
therefore,  be  guarded  at  the  outset,  lest  the  patient  be  led  to  expect 
a  too  speedy  relief  ;  and  in  some  cases,  in  spite  of  the  best  of  care, 
the  disease  will  frequently  return,  and  the  patient  can  scarcely  at 
any  time  consider  himself  as  perfectly  cured. 


Wounds  and  Foreign  Bodies. 

Wounds  of  the  rectum  may  be  either  contused  and  lacerated,  or 
incised.  The  latter  most  frequently  result  from  surgical  operations, 
and  may  be  intentionally  inflicted,  as  in  the  operations  for  fistula  or 
for  the  removal  of  tumors ;  or  the  result  of  accident,  as  in  the  opera- 
tion for  stone. 

Contused  and  lacerated  wounds  are  generally  the  result  of  acci- 
dent, and  perhaps  the  most  frequent  cause  of  such  an  injury  is  the 
perforation  of  the  bowel  with  an  enema  tube,  a  bougie,  or  a  urethral 
sound. 

The  gravity  of  this  accident  will  depend  upon  two  factors— 
whether  the  perforation  of  the  bowel  is  above  the  peritoneum,  and 
whether  the  enema  has  been  deposited  in  the  perirectal  tissues.     The 


WOUNDS   AND   FOREIGN   BODIES.  371 

latter  complication  will  be  followed  by  abscess  and  peritonitis,  and 
will  result  either  in  death  or  in  stricture  and  hstula.  If  the  wound  be 
uncomplicated  by  the  injection,  the  mere  puncture  may  heal  sponta- 
neously. It  is  oblique  from  below  upward,  and  this  greatly  favors 
spontaneous  healing  without  fecal  extravasation. 

Dr.  Achilles  ]N"ordmann,  of  Basel,  has  published  a  description  of 
twenty-five  bowel  lesions  due  to  the  administration  of  enemata.  They 
include  three  complete  perforations,  and  ulcers  and  wounds  of  vari- 
ous depths  and  sizes.  The  causes  of  these  wounds  seem  to  have 
been  the  use  of  defective  instruments,  ignorance  of  the  anatomy  of 
the  rectum,  catching  the  transverse  folds  on  the  end  of  the  tube,  ex- 
treme irritation  of  the  mucous  membrane  of  the  bowel,  and  obstruc- 
tions caused  by  such  conditions  as  a  foetal  head,  an  enlarged  pros- 
tate, or  a  misplaced  uterus. 

As  a  rule,  these  lesions  are  to  be  found  on  the  anterior  wall  from 
one  to  seven  centimetres  from  the  anus.  They  are  not  always  easy  to 
diagnosticate,  as  other  foreign  bodies  or  caustics  may  produce  simi- 
lar appearances.  Tubercular  or  hemorrhoidal  ulcers  may  be  mis- 
taken for  them.  A  perforating  w^ound  generally  results  in  serious 
periproctitis,  which  may  end  fatally,  or  in  stricture. 

Esmarch  has  met  with  four  cases  of  this  injury,  none  of  which 
were  fatal,  though  attended  by  much  local  trouble.  Velpeau  de- 
scribes eight  cases,  six  of  which  ended  fatally.  Passavant  observed 
five  cases,  one  fatal.  Chomel  has  had  two  fatal  results.  There  are  two 
preparations  in  St.  Bartholomew's  Hospital  showing  the  results  of 
this  accident,  one  in  a  man,  the  other  in  a  child  ten  years  of  age  (Es- 
march). 

Besides  these  most  common  injuries,  man}^  others  may  be  enu- 
merated. The  person  may  fall  upon  a  sharp  body,  as  the  point  of  an 
umbrella  (Bushe),  may  be  caught  upon  the  horn  of  an  animal  (Gun- 
drum,  Ashton),  or  may  be  impaled  upon  a  spike  (Esmarch). 

Thompson  describes  the  case  of  a  man,  aged  eighteen,  who  stated 
that  he  had  fallen  about  four  feet,  in  a  sitting  posture,  on  to  the  end 
of  the  upright  shaft  of  a  smith's  hammer,  which  he  described  as  hav- 
ing entered  his  seat  for  a  considerable  but  unknown  distance,  and 
requiring  some  amount  of  force  in  its  removal,  which  w^as  accom- 
plished by  a  lellow-workman.     He  had  very  little  pain  at  the  time  of 


372  SURGERY    OF   THE    KECTUM    AXD   PELVIS. 

the  accident,  and  walked  about  a  mile  to  the  infirmary  without  much 
trouble. 

On  examination  only  some  slight  bruising  was  found  around  the 
anus,  with  a  little  blood-stained  mucus.  Per  rectum  nothing  was 
detected.  The  abdominal  walls  were  quite  flaccid.  Examinations 
caused  no  pain.  He  complained,  however,  of  a  slight,  continuous, 
aching  pain  just  above  the  pubes.  Soon  after  admission  he  passed 
both  urine  and  fseces,  the  former  normal,  the  latter  soft  and  streaked 
with  blood.  Some  hours  later  he  passed  another  motion,  with  a  con- 
siderable quantity  of  clotted  blood  ;  the  suprapubic  pain  also  be- 
came more  intense,  but  the  abdominal  walls  still  remained  flaccid,  the 
face  was  very  pale,  the  pulse  rather  weak,  and  the  extremities  cold  ; 
but  the  patient  appeared  to  be  in  good  spirits,  answered  questions 
readily,  and  did  not  feel  unwell.  He  remained  in  this  condition  un- 
til midnight,  when  the  abdominal  pain  became  more  severe.  Symp- 
toms of  collapse  gradually  came  on,  and  he  died  at  8  a.m. 

At  the  necropsy,  on  the  same  morning,  the  peritoneum  was  every- 
where found  intense!}^  injected,  and  in  part  presented  a  thin  layer  of 
lymph.  There  was  a  marked  laceration  in  the  recto-vesical  pouch  a 
little  to  the  right  of  the  middle  line,  which  led  into  a  triangular 
opening  in  the  wall  of  the  rectum  about  three  inches  from  the  anus ; 
this  aperture  was  triangular,  its  base  measuring  one  inch  and  a  half, 
its  sides  an  inch  each.  At  the  brim  of  the  pelvis,  on  the  right  side, 
was  a  laceration  of  the  peritoneum  covering  the  psoas,  with  bruising 
of  the  subjacent  muscle.  The  mesenteric  glands  were  enlarged  and 
inflamed.  The  abdominal  cavitj^  contained  a  small  quantity  of  hard 
fffices ;  there  was  also  found  a  piece  of  cloth  corduroy  two  inches 
long  and  one  inch  and  a  half  in  breadth,  corresponding  in  texture  to 
the  patient's  trousers  and  to  an  aperture  in  their  seat. 

In  such  cases  the  accident  may  be  immediately  fatal  from  collapse, 
and  the  wound  in  the  rectum  may  be  complicated  by  a  wound  of  the 
peritoneum  or  of  any  of  the  adjacent  organs.  The  body  which  has 
done  the  injury  may  also  be  so  firmly  implanted  as  to  require  great 
force  and  an  anaesthetic  for  its  removal. 

The  rectum  is  not  infrequently  lacerated  in  childbirth ;  and 
although  such  wounds  are  generally  of  slight  extent,  Bushe  relates 
a  case  in  which  the  child's  head  was  passed  through  the  anus. 


WOUNDS    AND    FOREIGN    BODIES.  373 

It  has  also  happened  tliat  in  a  violent  effort  to  expel  a  mass  of 
hard  faeces  the  rectal  wall  has  given  way.  Mayo  relates  one  such 
case  in  a  woman  of  fort}^,  in  whom  the  rupture  was  in  the  recto- 
vaginal septum,  about  two  inclies  within  the  bowel.  Asliton  reports 
a  similar  case,  and  Bushe  another.  Such  a  rupture  may  be  either 
vertical  or  transverse,  will  be  marked  by  a  sharp  pain  at  the  moment 
of  the  accident,  and  will  be  followed  by  a  discharge  of  blood.  It  is 
doubtful  whether  it  ever  occurs  without  previous  disease  of  the  wall 
of  the  bowel.     (See  Rectal  Hernia.) 

Tlie  consideration  of  gunshot  wounds  comes  more  properly  within 
the  scope  of  military  surgery.  They  are  always  complicated  with 
injuries  of  other  parts,  and  are  generally  fatal  from  extravasation  of 
urine  or  fseces. 

The  complications  which  may  attend  a  wound  of  the  rectum  have 
already  been  hinted  at.  They  are  hemorrhage,  either  primary  or 
secondary;  fecal  infiltration  ;  purulent  infiltration  ;  peritonitis;  em- 
physema ;  hernia  ;  invagination ;  and  later,  stricture  and  fistula. 

When  fseces  are  forced  out  of  the  rectum  into  the  adjacent  tissue, 
diffuse  inflammation  and  gangrene  will  probablj^  result,  and  the  con- 
dition must  at  once  be  met  by  free  incisions  and  free  drainage,  as  has 
been  described  in  the  chapter  on  abscess.  The  danger  of  fecal  infil- 
tration may  be  lessened  by  a  diet  which  shall  prevent  fluid  passages, 
and  by  the  free  use  of  opium.  A  dilatation  or  a  free  division  of  the 
sphincter  is  also  to  be  recommended,  so  that  a  free  outlet  may  be  ac- 
corded to  the  contents  of  the  bowel. 

Emphysema,  as  a  result  of  a  perforation,  is  generally  confined  to 
the  perineum,  but  may  be  diffuse.  It  is  very  apt  to  be  fatal  from 
diffuse  inflammation  and  septicsemia,  due  to  the  putrid  nature  of  the 
gas,  and  is  to  be  met  by  free  incisions. 

Wounds  of  the  bladder  or  urethra  communicating  with  the  rectum 
are  to  be  met  by  providing  for  the  free  issue  of  the  urine.  This  may 
be  done  by  catheterism,  by  aspiration,  or  by  free  division  of  the 
sphincter. 

Where  none  of  these  complications  exist,  a  fresh  wound  of  the 
rectum  ma}^  close  by  first  intention,  and  an  effort  should  always  be 
made  to  secure  this  by  rest  in  bed,  by  emptying  the  bowel,  and  keep- 
ing it  empty  by  frequent  washings  with  water,  and  by  the  use  of 


374  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

opium.  Healing  by  granulation  will,  however,  be  the  rule.  In  some 
cases — such,  for  example,  as  laceration  in  childbirth — sutures  may 
be  at  once  applied. 

As  Ball  points  out,  the  proper  method  of  treatment  for  punctured 
wounds  low  down  in  the  rectum  is  free  incision  through  the  sphincter 
up  to  the  wound  to  allow  of  drainage. 

Of  gunshot  wounds  of  the  rectum  during  the  Civil  War,  Otis  col- 
lected 103  cases,  with  a  mortality  of  42.7  per  cent.;  in  34  of  these  the 
bladder  also  was  wounded,  with  a  mortality  of  41.17  per  cent. 

Foreign  Bodies  which  have  teen  Swallowed. 

Medical  literature  is  f uU  of  curious  cases  in  which  foreign  bodies 
have  been  swallowed,  either  accidentally  or  by  design,  and  have  in 
some  cases  passed  the  full  length  of  the  alimentary  canal  and  been 
safely  voided  with  fseces,  or  in  others  have  become  entangled  in  the 
mucous  membrane  and  given  rise  to  much  trouble. 

Every  practitioner  is  familiar  with  cases  of  peach-stones  and  coins 
which  have  been  accidentally  swallowed,  and  knows  how  generally 
such  substances  take  care  of  themselves  and  cause  no  symptoms 
after  once  passing  the  CBsophagus.  Much  larger  substances,  such  as 
whole  or  partial  sets  of  false  teeth,  and  the  various  things  with  which 
performers  in  travelling  shows  entertain  an  audience,  may  also  be 
passed  in  safety. 

To  show  what  nature  is  capable  of  in  this  line,  it  may  be  well  to 
enumerate  the  substances  which  were  swallowed  and  safely  voided  by 
a  certain  lunatic,  now  become  famous. 

The  patient  stated  that  she  had  been  swallowing  nails,  etc.,  and  a 
dose  of  castor  oil  brought  away  two  pieces  of  faience  one  or  two  cen- 
timetres long  and  about  the  same  breadth,  two  nails,  and  a  pebble. 
During  the  following  six  weeks  she  passed  nineteen  large  pointed 
nails,  a  screw  seven  centimetres  long,  numerous  fragments  of  glass  and 
china,  a  piece  of  a  needle,  two  knitting  needles,  fragments  of  whale- 
bone, etc.,  amounting  in  all  to  three  hundred  grammes.  During  all 
this  time  the  patient  ate  and  drank  as  usual,  and  seemed  in  ordinary 
health. 

Professor  Agnew  "  saw  in  the  dissecting  room  of  the  Philadelphia 


WOUNDS   AND   FOREIGN   BODIES.  375 

School  of  Anatomy  a  female  subject,  afterward  learned  to  have  been 
insane,  in  whose  intestinal  canal  from  jejnnum  to  rectum  were  found 
three  spools  of  cotton,  partially  unwound  ;  two  roller  bandages,  one 
of  them  two  and  a  half  inches  wide  and  one  inch  thick,  the  other  was 
partially  unrolled,  one  end  being  in  the  ileum,  the  other  in  the  rec- 
tum ;  a  number  of  skeins  of  thread,  a  quantity  being  packed  tightly 
in  the  caecum  ;  and,  finally,  a  pair  of  suspenders.'- 

Professor  Gross  records  the  "  case  of  a  man  who  swallowed  a  bar 
of  lead,  ten  inches  long,  upward  of  six  lines  in  diameter,  and  one 
pound  in  weight,  whilst  performing  some  tricks  of  legerdemain," 
which  was  removed  by  gastrotomy,  and  the  patient  recovered  in  two 
weeks.  He  also  mentioned  another  case  in  which  a  teaspoon  was 
swallowed  whilst  the  patient  was  in  a  paroxysm  of  delirium,  which 
was  removed  from  the  ileum  by  enterotomy,  recovery  taking  place 
in  a  few  weeks. 

It  would  be  beyond  the  scope  of  a  work  such  as  this  to  attempt 
to  deal  with  the  whole  question  of  foreign  bodies  in  the  alimentary 
canal,  and  the  accidents  which  may  attend  them.  In  a  general  way, 
the  prognosis  is  good  unless  the  foreign  body  be  a  very  ragged  one, 
or  a  large,  sharp  one,  like  a  fork  ;  and  the  treatment  consists  in  giv- 
ing a  diet,  like  bread  and  fruit,  which  will  cause  copious  stools,  with 
little  drink,  and  the  avoidance  of  exercise  such  as  walking. 

If  complications  arise,  they  must  be  treated  on  general  surgical 
principles ;  and  at  the  present  day  no  patient  would  be  allowed  to 
die  from  the  effects  of  a  foreign  substance  in  the  stomach  or  intes- 
tines without  a  surgical  operation  for  its  removal,  provided  only  the 
diagnosis  were  clear. 

The  complications  which  may  attend  the  detention  of  such  sub- 
stances in  the  rectal  pouch  just  above  the  internal  sphincter  are 
ulceration  with  perforation,  hemorrhage,  and  abscess.  Ulceration 
may  be  caused  by  the  pressure  of  a  large  body,  and  may  cover  a  con- 
siderable space  ;  or  it  may  be  caused  by  the  pressure  of  the  sharp 
ends  of  a  smaller  body,  in  which  case  the  spots  of  ulceration  will  be 
smaller,  and  may  be  located  at  two  opposite  points  in  the  rectum. 
As  a  result  of  ulceration  there  will  be  more  or  less  pain,  purulent  dis- 
charge, and  perhaps  also  a  sharp  hemorrhage  from  the  erosion  of  a 
vessel.     When  perforation  of  the  wall  of  the  bowel  has  occurred, 


'.llo  SURGERY  OF  THE  RECTUM  AND  PELVIS. 

inflammatory  action  is  almost  sure  to  be  excited  in  the  surrounding 
parts,  and  tliis  may  vary  greatly  in  its  extent  and  gravity. 

If  tlie  injury  be  above  the  point  of  reflexion  of  the  peritoneum,  it 
may  cause  either  a  localized  or  a  general  peritonitis.  A  general  peri- 
tonitis caused  in  this  way  will  be  fatal,  as  it  is  also  generally  ac- 
companied by  more  or  less  extravasation  of  faeces.  A  circumscribed 
peritonitis  with  formation  of  an  abscess  is  a  less  fatal  complication. 

Under  these  circumstances  the  usual  signs  of  pelvic  abscess  will 
be  present — fever,  pain  on  pressure,  tympanites,  painful  defecation 
and  urination — and  by  careful  examination  a  tumor  may  be  dis- 
covered, either  through  the  rectum  or  at  the  bottom  of  the  iliac  fossa. 
Such  cases,  when  the  tumor  is  on  the  right  side,  are  often  mistaken 
for  cases  of  appendicitis,  but  the  tumor  is  not  in  the  same  location  ; 
it  is  deeper  and  nearer  the  median  line. 

Such  an  inflammation  may  terminate  in  resolution,  provided  the 
cause  be  discovered  and  removed  ;  but  the  usual  termination  is  in 
suppuration,  and  the  pus,  if  not  removed  by  the  surgeon,  ma}^  find 
its  way  into  the  general  peritoneal  cavity  or  into  the  bladder  or  rec- 
tum. Abscesses  of  the  superior  pelvi-rectal  space  have  alread}^  been 
described,  and  those  which  are  due  to  foreign  bodies  in  the  bowel  do 
not  differ  from  them  in  general  character. 

When  the  focus  of  inflammation  is  located  below  the  reflexion  of 
the  peritoneum,  the  prognosis  is  less  grave.  Phlegmonous  abscess 
may  form  in  the  ischio-rectal  fossa,  and  must  be  treated  according  to 
the  rules  alreadj^  laid  down  ;  but  here  the  difliculty  is  well  within 
the  reach  of  the  surgeon,  and  a  cure  may  confidently  be  looked  for 
by  proper  care. 

Foreign   Bodies  Introduced  per  Anum. 

A  classification  of  these  cases  is  useless.  The  foreign  bodies  may 
be  introduced  through  traumatism  ;  by  the  patient  in  an  honest  en- 
deavor to  relieve  himself  of  piles  or  prolapse  ;  by  the  surgeon  for  the 
purpose  of  relieving  rectal  disease.  They  are  often  introduced  in  a 
spirit  of  revenge  or  of  trickery  ;  and  most  often  of  all  they  are  lost 
in  the  practice  of  an  unnatural  vice.  Edward  II.  is  said  to  have  met 
his  death  by  having  a  red-hot  iron  thrust  into   the  rectum.     "We 


WOUNDS    AND    FOREIGN   BODIES.  377 

seized  the  king,"  said  one  of  the  murderers,  "and  threw  liim  forcibly 
upon  the  couch,  and,  wliilst  I  kept  liini  tliere  by  the  assistance  of  a 
table,  with  a  pillow  on  his  face,  Gurney  inserted  through  a  horn-tube 
a  red-hot  iron  into  his  bowels." 

A  punishment  for  adultery  among  the  Greeks  is  said  to  have  been 
the  introduction  into  the  rectum  of  a  peeled  radish  covered  with  hot 
ashes  ;  and  cases  in  which  patients  have  fallen  upon  sharp  and  fra- 
gile objects,  such  as  the  wooden  pickets  of  a  fence,  which  have 
broken  off  and  remained  in  the  rectum,  are  on  record. 

The  list  of  foreign  bodies  which  have  been  lost  in  the  rectum  by 
ignorant  persons,  in  attempts  to  check  a  diarrhoea  or  to  prevent  the 
descent  of  piles  or  prolapse,  is  a  very  long  one,  and  includes  such 
substances  as  bottles,  sticks  of  wood,  and  round  stones,  some  of 
them  of  a  size  relatively  enormous  ;  and  the  use  of  the  rectal  pouch 
by  criminals  for  the  purposes  of  concealment  is  well  known  to  the 
police. 

In  the  Museum  of  Anatomy  and  Pathology  at  Copenhagen  is  a 
longish,  oval,  flat  stone,  about  six  and  three-quarter  inches  long,  two 
and  a  half  inches  wide,  one  and  a  half  inches  thick,  and  weighing 
nearly  two  pounds,  which  a  patient  in  Bornholm  introduced  into  his 
rectum  to  prevent  prolapse,  from  which  he  had  for  a  long  time 
suffered.  The  stone  was  extracted  by  a  surgeon,  Frantz  Dyhr,  in 
1756. 

A  little  case,  with  very  ingenious  housebreaking  and  other  thieves' 
instruments,  was  found  by  Dr.  Closmadeuc  at  the  necropsy  of  a  man 
in  the  prison  at  Vannes.  The  man  had  died  of  acute  peritonitis, 
from  which  he  had  suffered  seven  days.  During  his  illness  a  hard, 
rather  large  body  was  felt  in  the  left  side  of  the  hypogastrium  ;  he 
said  that  it  was  a  piece  of  wood  containing  money,  which  he  had 
introduced  into  the  rectum  ;  this,  on  exploration  in  the  meantime, 
was  found  empty. 

On  section,  the  case,  which  was  cylindro-conical  in  form,  lay  in 
the  transverse  colon,  with  its  apex  directed  toward  the  caecum  ;  it 
was  of  iron,  and  was  wrapped  in  apiece  of  lamb's  mesenteiy ;  it 
weighed  about  twenty-three  ounces,  was  about  six  and  a  third 
inches  long  and  five  and  a  half  in  circumference,  and  contained 
thirteen  tools  and  some  coins. 


378  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

A  depraved  sexual  appetite  has  been  mentioned  as  accounting  for 
the  presence  of  many  foreign  bodies.  It  is  known  that  sexual  or- 
gasm may  be  excited  by  stimulating  the  reflex  power  of  the  rectum, 
and  it  is  probable  that  at  the  moment  when  the  orgasm  is  at  its 
height  the  body  used  to  produce  it  is  allowed  to  escape  fiom  the 
hand  and  is  lost  within  the  bowel.  This  is  a  habit  which  will  never 
be  acknowledged  by  its  victims,  but  which  may  often  be  assumed  to 
exist  by  the  surgeon  in  depraved  patients. 

The  bodies  used  for  this  purpose  are  generally  smooth,  long,  and 
round,  such  as  glass  bottles  and  pieces  of  wood. 

It  would  be  interesting  to  enumerate  the  foreign  bodies  which 
have  been  removed  from  this  part  of  the  body,  and  the  list  would  be 
startling  from  the  strangeness  of  the  different  articles;  but  enough 
has  been  said  to  indicate  that  almost  anything,  from  a  conical  stone 
to  a  club  or  a  coffee-cup,  may  be  encountered  by  the  surgeon,  and  to 
indicate  the  size  of  the  body  which  the  sphincter  will  allow  to  pass. 
Among  them  may  be  mentioned  beer  glasses,  mushroom  bottles, 
wooden  pepper  boxes,  wine  bottles  of  all  kinds,  lamp  chimneys,  and 
a  part  of  the  wooden  handle  of  a  baker's  shovel  twenty-two  centi- 
metres in  length. 

A  foreign  substance  may  remain  in  the  rectum  for  a  considerable 
time  and  finally  be  expelled  spontaneously,  as  in  the  following  case 
reported  by  Weigand. 

"A  farmer,  aged  sixty-eight  years,  of  a  robust  constitution,  but 
somewhat  stupid,  introduced  into  the  anus  a  cylindrical  piece  of 
wood  for  the  purpose  of  relieving  his  obstinate  constipation.  How- 
ever, he  performed  the  manipulation  so  unskilfully  that  the  piece  of 
wood  broke  and  remained  partially  within  the  rectum.  All  attempts 
made  to  remove  the  foreign  body  failed  ;  two  days  later  he  suf- 
fered from  abdominal  and  lumbar  pains,  dysuria,  and  constipation. 
Weigand,  being  consulted  by  the  physician,  recognized  the  symp- 
toms of  enteritis.  As  the  introduction  of  a  finger  into  the  rectum 
did  not  demonstrate  the  presence  of  a  foreign  body,  he  restricted 
himself  to  combating  the  inflammatory  symptoms  and  pain  (calomel, 
enemata,  narcotics,  leeches), 

"On  the  eleventh  day  a  purulent,  sanguinolent,  fetid  fluid  was 
evacuated,  after  which  the  patient  felt  remarkably  relieved  ;  but  it 


WOUNDS   AND   FOREIGN   BODIES.  379 

■was  impossible  to  discover  any  trace  of  the  piece  of  wood.  Weigand 
then  expressed  serious  doubts  as  to  whether  a  foreign  body  was 
really  contained  in  the  rectum ;  but  as  the  patient  resolutely  main- 
tained that  he  continued  to  feel  the  piece  of  wood,  renewed  search 
was  made,  until  the  finger,  being  introduced  far  in,  encountered  a 
rough,  hard  object  which  it  was  impossible  to  seize  for  want  of  proper 
instruments. 

"As  circumstances  did  not  indicate  a  necessity  for  more  active 
treatment,  Weigand  contented  himself  with  giving  the  patient  from 
time  to  time  two  or  three  spoonfuls  of  castor  oil,  which  always  pro- 
duced the  discharge  of  a  small  amount  of  muco-sanguinolent  fgeces. 
At  this  time  the  lumbar  and  abdominal  pains  again  appeared  more 
^frequently,  and,  on  the  other  hand,  the  patient's  former  appetite 
being  gradually  restored,  he  walked  about  and  attended  to  light 
■domestic  duties.  On  the  thirty-first  day  after  the  accident,  after 
having  taken  three  spoonfuls  of  castor  oil,  he  stated  that  he  had  an 
intense  desire  to  go  to  stool,  when,  in  addition  to  blood  and  pus,  the 
piece  of  wood  made  its  appearance,  0.1357  m.  long,  0.027  thick,  cylin- 
drical, serrated  at  the  broken  end,  and  roughened  at  the  cylindrical 
surface  ;  in  fact,  it  was  the  end  of  a  pole  with  which  bean  vines  are 
propped.  The  patient  recovered  entirely  without  having  been  sub- 
jected to  any  further  treatment"  (Poulet). 

Prognosis. 

The  prognosis  in  cases  of  foreign  bodies  will  depend  greatly  upon 
their  size  and  nature.  A  long  body  like  a  piece  of  wood  may  go  so 
far  up  the  bowel  as  to  do  fatal  damage  before  its  removal ;  and  a 
fragile  body  like  glass  may  cause  fatal  injury  in  the  attempt  to  re- 
move it.  Again,  the  prognosis  depends  in  a  great  measure  upon  the 
surgical  ability  of  the  one  in  charge  of  the  case.  A  little  bungling 
in  the  treatment  may  at  any  moment  change  a  case  which  promises 
well  into  a  fatal  one. 

Finally,  much  will  depend  upon  the  length  of  time  during  which 
the  body  has  remained  in  the  rectum  ;  and  it  is  not  very  uncommon 
for  patients  who  have  met  with  an  accident  in  the  practice  of  this 
secret  vice  to  conceal  the  real  nature  of  the  trouble,  which  they 


380  SURGERY    OF   THE    RECTUM    AXD    PELVIS. 

well  understand,  till  they  are  forced  b}^  suffering  to  confess.  In  this 
way  a  week's  valuable  time  maybe  lost  and  a  fatal  amount  of  in- 
jury be  done. 

Treatment. 

Each  case  of  foreign  body  must  be  treated  b}'  itself,  and,  besides 
a  few  general  principles  which  apply  equally  to  all  cases,  the  surgeon 
will  be  left  entirely  to  his  own  ingenuity.  The  one  guiding  principle- 
should  be  to  avoid  doing  fresh  injury  in  the  attempt  at  removal. 
Only  the  smaller  and  least  friable  of  bodies  can  be  removed  without 
a  previous  dilatation  of  the  sphincter  under  ether,  and  in  most  cases 
it  will  be  adv'isable  to  incise  the  anus  in  the  median  line  down  to  the 
tip  of  the  coccyx  as  a  preparatory  measure  to  all  treatment.  This- 
step  will  sometimes  render  a  body  movable  which  before  was  abso- 
lutely immovable,  and  thus  open  the  way  for  its  extraction. 

Having  opened  the  way  to  the  bodj^,  it  may  sometimes  be  re- 
moved by  passing  the  whole  hand  into  the  rectum  and  seizing  it. 
At  other  times  forceps  may  be  used  with  advantage,  and  these  may 
be  of  an}"  shape  which  seems  best  to  answer  the  purpose  intended,. 
including  the  obstetric  forceps,  which  have  been  found  useful  in 
many  cases.  If  a  bottle  has  been  introduced  with  the  mouth  down- 
ward, a  string  ma}'  be  secured  around  the  neck  for  the  purpose  of 
traction  ;  but,  unfortunately,  in  almost  all  cases  the  position  will  be 
reversed.  In  cases  of  long  bodies  the  lower  end  is  not  infrequently 
firmly  wedged  in  the  hollow  of  the  sacrum — so  firmly  as  to  resist  all 
efforts  at  dislodgement.  Under  such  circumstances  fatal  injury  may 
easily  be  done  by  the  operator  by  persistence  in  the  attempt. 

Above  all  things  the  surgeon  must  avoid  breaking  such  a  sub- 
stance as  a  cup,  for  experience  has  proved  that,  after  this  has  hap- 
pened, removal  without  causing  great  injury  is  almost  impossible. 

Certain  complications  may  at  any  time  arise  in  the  treatment  of 
these  cases,  one  of  which  is  recorded  by  Desault.  A  man,  aged 
forty-seven,  entered  the  Hotel  Dieu  on  April  17.  1762,  in  order 
to  have  a  crockery  vessel  extracted  from  his  rectum,  which  he  had 
introduced  a  week  previously  in  order  to  overcome,  as  he  said,  his 
obstinate  constipation.  This  vessel  was  a  preserve  jar,  the  handle 
of  which  was  broken  and  the  bottom  detached.     It  was  conical  in 


WOUNDS    AND    FOREIGN"    BODIES.  381 

shape  and  three  inches  long  ;  it  had  been  introduced  by  the  smaller 
end,  which  was  two  inches  in  diameter. 

When  the  patient  presented  himself  at  the  hospital  he  had  already 
made  efforts  to  extract  the  foreign  body,  but  an  escape  of  blood  and 
the  excessive  pains  had  compelled  him  to  suspend  his  efforts.  The 
upper  part  of  the  rectum  was  infolded  and  invaginated  in  the  vessel, 
and  formed  a  very  hard  tumor  which  filled  it  completely.  The  sur- 
rounding parts  were  inflamed,  and  this  fact  rendered  the  extraction 
more  difficult. 

Desault  made  the  patient  lie  upon  the  side,  and  then,  separating 
the  intestine  from  the  walls  of  the  vessel,  he  succeeded  in  seizing  the 
latter  with  a  strong  extractor,  which  he  pushed  up  as  far  as  possible, 
and  which  was  held  by  an  assistant. 

By  means  of  this  point  of  support,  and  with  another  extractor  in- 
troduced in  the  same  manner,  he  succeeded  in  breaking  the  vessel  and 
in  extracting  it  in  small  pieces  without  wounding  the  rectum.  The 
operation  was  neither  long  nor  painful,  though  it  was  necessary  to 
introduce  the  extractors  a  large  number  of  times.  After  all  the 
pieces  had  been  removed,  Desault  pushed  back  the  inverted  portion 
of  the  rectum  by  means  of  a  charjDie  tampon  six  inches  long  and  two 
tind  a  half  in  diameter,  which  he  pushed  in  altogether  after  having 
covered  it  with  cerate.  Below  this  were  placed  a  large  amount  of 
<?harpie,  several  compresses,  and  a  triangular  bandage  which  sup- 
ported the  whole  dressing.  The  dressing  was  renewed  twice  a  day 
on  account  of  the  relaxation,  which  did  not  cease  till  the  sixth  day. 
Then  the  intestine  no  longer  protruded  when  the  patient  went  to 
stool,  and  such  large  tampons  were  not  required.  They  were  discon- 
tinued entirely  after  the  tenth  day,  when  the  ruptures  had  cicatrized, 
and  the  man  left  the  hospital  entirely  cured  two  weeks  after  the 
operation. 

In  cases  where  a  long  body  has  become  firmly  wedged  into  the 
lower  end  in  the  hollow  of  the  sacrum,  the  proper  treatment  consists 
in  opening  the  abdomen,  and  this  should  be  done  after  an  attempt 
to  remove  it  ^:>er  anuin  has  been  continued  a  reasonable  time,  and 
before  injury  has  been  done  in  such  an  attempt. 

The  incision  may  be  made  either  in  the  median  line  or  in  the 
groin.    In  the  "  Surgical  History  of  the  War  of  the  Rebellion,"  vol.  ii., 


382  SURGERY   OF   THE   RECTUM   AJfD   PELVIS. 

page  322,  there  is  a  history  of  one  such  operation  performed  upon  a 
sailor  who  had  introduced  a  stone  five  and  a  quarter  inches  long  by 
three  wide.  The  colon  liad  been  perforated,  and  the  stone  was  re- 
moved from  the  peritoneal  cavity  by  an  incision  near  the  umbilicus. 
The  man  recovered. 

The  oldest  known  case  w^as  reported  by  Realli  in  the  Bulletin  de 
Societe  Mklicli.  and  Gazette  Medicale,  July,  1851,  and,  being  the  one- 
which  has  served  as  a  guide  for  all  subsequent  ones,  we  give  it  in 

full : 

"On  December  18,  1848,  a  peasant  was  brought  to  the  hospital 
of  Orvieto  in  a  condition  of  extreme  weakness.  Nine  days  pre- 
viously, having  hit  upon  the  ingenious  idea  that  if  he  prevented  the- 
discharge  of  food  he  could  limit  the  quantity  to  be  swallowed,  he 
introduced  a  piece  of  wood  into  the  rectum  ;  all  his  attempts  at  re- 
moval only  served  to  push  it  in  still  farther.  The  finger  could  only 
touch  the  end  of  the  object,  and  it  was  firmly  fixed  in  such  a  manner 
as  not  to  yield  to  any  tractions  which  could  be  made  upon  it  with 
such  a  slight  purchase. 

"After  the  failure  of  all  attempts  at  removal,  the  foreign  body 
completely  obliterating  the  intestinal  cavity,  and  the  patient  being 
threatened  with  death  from  his  atrocious  sufferings,  Realli  decided 
to  operate.  After  having  cut  the  abdominal  walls  on  the  left  side, 
he  could  distinctly  feel  the  stake  in  the  descending  colon.  He  de- 
sired to  push  it  down  to  the  anus,  but  the  attempts  proved  unsuc- 
cessful and  he  was  compelled  to  incise  the  intestine.  Only  after  this 
was  done  could  he  remove  the  body,  which  was  ten  centimetres  long 
and  more  than  three  centimetres  in  diameter  at  the  base.  The  point 
was  rounded  and  very  soft.  No  fffices  were  retained  above  the  plug, 
but  the  mucous  membrane  was  blackish,  the  peritoneal  coat  strongly 
injected,  and  the  thickness  of  the  intestinal  wall  markedly  increased. 

"The  wound  in  the  intestine  w^as  united  by  a  suture,  which  was 
applied  according  to  Jobert's  plan.  The  lips  of  the  wound  in  the 
abdomen  were  united  by  means  of  an  interrupted  suture.  Cold,  and 
then  iced  applications  were  made  over  the  operated  region.  Two 
doses  of  castor  oil  were  administered.  There  was  a  purulent  dis- 
charge from  the  anus.  During  the  first  few  days  the  tumefaction  of 
the  walls  of  the  intestines  prevented  the  advance  of  f?eces  and  caused 


WOUNDS   AND   FOREIGN   BODIES. 


383 


Pig.  207. 
Stone  Removed  from  Peritoneal  Cavity.     Natural  Size. 


3tS4  SURGERY    OF    THE   RECTUM   AND    PELVIS. 

meteorism  and  vomiting.  Three  bleedings,  two  applications  of 
leeches,  and  a  few  doses  of  castor  oil  put  an  end  to  these  symptoms, 
which  had  acquired  an  alarming  character.  The  evacuations  from 
the  bowels  were  again  passed  on  the  fifth  day.  Toward  the  four- 
teenth day  the  wounds  had  cicatrized.  Two  years  later  the  health 
remained  perfect." 

John  S.,  sailor,  aged  forty-one,  had  been  in  the  habit  of  crowd- 
ing either  a  belaying  pin  or  an  eight-ounce  bottle  into  the  rectum  to 
relieve  a  retention  of  urine  which  was  of  a  spasmodic  nature  and 
which  recurred  frequently.  .June  13,  1870,  not  having  any  bottle, 
he  obtained  a  pebble,  five  inches  long  by  three  in  width,  and  weigh- 
ing two  pounds,  and,  having  greased  it,  he  applied  it  to  the  anus  and 
sat  upon  it.  Suddenly  the  stone  slipped  Into  the  rectum  above  the 
sphincter,  and  although  the  patient  could  touch  he  could  not  remove 
it.  A  physician  was  called,  who  endeavored  to  pull  it  out  with  wire 
loops,  but  the  more  he  tried  the  farther  the  stone  receded  from  the 
anus.  A  final  efi'ort  was  made  by  causing  the  captain's  boy  to  pass 
in  his  hand  "up  to  the  shoulder;"  he  could  reach  the  pebble,  but 
could  not  draw  it  down.  The  patient  was  then  brought  to  Boston, 
and  Dr.  Thorndike  called,  June  15th.  He  found  him  suffering  from 
peritonitis,  indicated  by  tympanites,  pain,  high  pulse  and  tempera- 
ture, vomiting,  and  brown  tongue.  The  patient  having  been  ether- 
ized. Dr.  T.  passed  his  hand  into  the  rectum  ;  he  could  feel  the  stone 
high  up  in  the  abdominal  cavity,  but  his  hand  and  arm  were  so 
cramped  by  the  want  of  space  that  it  was  impossible  to  seize  the  for- 
eign body.  An  incision,  five  inches  long,  was  then  made,  parallel 
with  the  outer  border  of  the  left  rectus  muscle,  extending  upward  to 
a  point  two  inches  above  the  umbilicus  ;  the  peritoneal  cavity  was 
opened,  and  the  stone  found  lying  among  the  intestines  just  below 
the  stomach  (Fig.  207).  The  bowels  were  highly  congested,  but  not 
adherent  to  each  other.  The  aperture  through  which  the  stone  es- 
caped from  the  intestine  was  about  eight  inches  above  the  anus. 
The  external  wound  was  closed  with  six  silk  sutures. 

"The  patient  had  a  thin,  yellow  dejection  three  days  after  the 
operation.  No  blood  ever  came  from  the  rectum.  The  vomiting, 
hiccough,  tympanites,  and  pain  gradually  subsided,  and  he  got  out 
of  bed  in  twelve  days." 


WOUNDS   AND   FOREIGN   BODIES. 


385 


Fig.  208. 
Stick  Removed  from  Rectum.     Natural  Size. 


25 


386  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

Fig.  208  represents  a  willow  stick  introduced  by  the  patient  five 
years  before  "to  relieve  constipation."  A  recto-vesical  fistula  had 
been  formed,  and  the  stick  had  become  encrusted  with  phosphates. 

These  cases  indicate  with  sufficient  clearness  the  general  rules 
which  should  guide  the  practitioner.  The  operation  is  applicable 
only  to  bodies  high  up  in  the  rectum.  The  point  of  incision  may  be 
in  the  median  line,  over  the  sigmoid  flexure  in  the  left  loin,  or  over 
what  seems  to  be  the  most  prominent  point  of  the  foreign  body, 
wherever  that  may  be.  If  the  intestine  is  healthy  it  may  be  closed 
and  returned  into  the  body ;  if  not,  an  artificial  anus  should  be 
made  at  the  point  of  incision. 

It  is  worthy  of  note  that  ail  of  the  cases  thus  far  recorded  have 
ended  in  recovery. 

Spasm  of  the  Sphincter. 

Spasm  of  the  sphincter  without  the  presence  of  any  other  rectal 
affection  is  undoubtedly  rare.  Its  general  character  may  perhaps 
best  be  shown  by  the  citation  of  the  following  cases. 

Case. — Spasm  of  the  Sphincter. — Physician,  aged  twenty-eight. 
The  patient  was  a  man  decidedly  given  to  thinking  about  his  own 
health,  and,  though  generally  well,  not  at  all  robust.  He  came  to 
me  complaining  of  a- sense  of  discomfort  about  the  rectum,  accom- 
panied by  difficulty  in  defecation.  The  discomfort  seldom  amounted 
to  actual  pain,  and  he  had  noticed  that  when  he  was  away  on  his 
summer  vacations  he  was  always  better  and  in  fact  perfectly  well. 
Nevertheless  the  trouble  in  defecation  had  increased  so  markedly 
during  the  past  few  months  that  he  was  fully  convinced  that  he  was 
suffering  from  actual  stricture. 

An  attempt  at  digital  examination  caused  the  most  exquisite 
suffering,  forcing  the  patient  to  cry  out  in  agony,  and  yet  there  was 
entire  absence  of  any  lesion. 

The  treatment  was  based  upon  the  fact  which  he  had  himself 
noted,  that  when  his  general  condition  was  improved  the  local  trou- 
ble ceased  ;  and  the  patient  was  cured  by  purely  general  measures 
looking  toward  the  building-up  of  the  system. 

Qk^^.— Spasm  of  the  Sphincter.— 'Professional  man,  aged  thirty. 
In  this  case  also  the  only  symptom  complained  of  was  pain  on  defe- 


SPASM   OF  THE   SPHINCTER.  387 

cation,  sometimes  severe,  sometimes  sliglit.  The  history  given 
pointed  so  strongly  toward  the  existence  of  a  fissure  that  I  ether- 
ized the  patient,  fully  expecting  to  cure  him  by  stretching  the 
sphincter.  He  v^as  entirely  cured  by  stretching  the  muscle,  but, 
to  my  surprise,  a  most  careful  examination  revealed  no  disease  ; 
and,  being  dubious  myself  about  the  existence  of  spasm  without 
fissure,  the  examination  was  a  very  thorough  one.  This  patient 
was  also  a  man  of  sedentary  habits  and  of  rather  a  nervous  character. 

The  following  case  is  taken  from  Syme,  and  is  characterized  by 
him  as  a  remarkable  instance  of  the  affection  :  "I  was  asked  to  see 
a  gentleman,  about  sixty  years  of  age,  who  stated  that  a  few  weeks 
before,  after  sitting  out  a  long  debate  in  the  House  of  Commons,  he 
had  felt  extreme  difficulty  in  evacuating  the  bowels,  having  previ- 
ously for  several  years  experienced  more  or  less  uneasiness  from  this 
source  ;  that  he  had  consulted  a  physician  and  surgeon  in  London^ 
who  prescribed  laxatives  without  affording  relief  ;  and  that  his  com- 
plaint had  continued  so  as  at  length  to  confine  him  to  bed.  I  pro- 
posed an  enema,  which  was  at  once  objected  to  on  the  ground  that 
the  anus  would  not  admit  the  smallest-sized  tube. 

"  Suspicion  being  thus  excited,  the  anus  was  examined  and  found 
to  present  the  characteristic  features  of  spasmodic  stricture.  Hav- 
ing explained  my  views  of  the  case,  I  gently  insinuated  the  narrow 
sheath  of  a  'bistoury  cacJie  which  I  happened  to  have  with  me,  and 
then,  expanding  the  blade,  withdrew  it  so  as  to  make  an  incision  on 
one  side  of  the  orifice.  A  copious  stool  immediately  followed,  and 
the  patient  was  at  once  completely  relieved  from  his  complaint." 

With  regard  to  this  much-disputed  affection,  a  citation  of  au- 
thorities may  be  useful.  Syme  believed  that  spasm  existed  as  an  in- 
dependent condition  without  morbid  change  ;  that,  though  there 
could  be  no  doubt  that  spasm  and  fissure  frequently  existed  to- 
gether, it  was  not  reconcilable  with  the  facts  met  with  in  practice, 
that  spasmodic  stricture  was  alwaj^s  of  secondary  origin  and  depend- 
ent upon  the  fissure.  He  says:  "In  a  considerable  number  of 
cases  I  have  found  the  sphincter  firmly  contracted  without  any  per- 
ceptible fissure  or  abrasion  of  the  surface." 

Mayo  describes  spasm  of  the  sphincter  as  a  kind  of  cramp  which 
often  comes  on  suddenly,  sometimes  at   night   during   sleep.     The 


388  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

paroxysms  may  occur  daily  or  two  or  three  times  a  year  ;  and  the 
attack  may  come  on  gradually  and  cause  uneasiness  for  two  or  three 
days,  and  then  pass  away,  or  its  coming  and  going  may  be  sudden. 
He  says  :  "  There  are  cases  in  which  the  disease  produces  long-con- 
tinued and  permanent  suffering  ;  in  which  the  anus  becomes  perma- 
nently contracted  and  hardened,  constituting,  therefore,  a  permanent 
stricture,  and  generally  combining  both  permanent  and  spasmodic 
contraction.  The  motions  are  passed  with  an  effort  and  with  pain, 
and  all  the  common  symptoms  of  stricture  of  the  rectum  are 
present." 

Allingham  says:  "Spasm  of  the  sphincter  has  been  said  to  be 
the  cause  of  impaction,  but  I  have  more  often  thought  the  reverse 
w^as  the  case,  and  the  impaction  the  cause  of  the  spasm.  I  must, 
however,  acknowledge  that  spasm  is  often  the  cause  of  the  constipa- 
tion which  is  the  forerunner  of  impaction.  In  impaction,  spasm  of 
the  sphincter  always  exists,  in  some  instances  to  such  a  degree  that, 
when  the  patient  strained,  I  have  observed  the  anus  protruded  like  a 
nipple,  and  an  injection  returned  in  a  fine  stream  as  if  coming  out  of 
a  squirt.  I  have  certainly  met  with  cases  of  idiopathic  spasm  of  the 
sphincter,  usually  in  elderly,  nervous  single  women,  and  though  no 
impaction  was  present,  costiveness  was." 

Quain  concludes  that  "where  pain,  brought  on  by  fecal  evacua- 
tions and  continuing  after  them,  happens  to  be  present,  the  fault 
— the  morbid  condition — is  not  in  the  sphincter,  but  in  the  skin  or 
mucous  membrane  covering  it,  and  that  the  division  of  the  muscle  is 
not  required  in  order  to  remove  the  patient's  suffering."  In  other 
v7ords,  that  spasm  is  always  dependent  upon  fissure.  Boyer  treats  of 
"constriction  with  fissure"  and  "  constriction  without  fissure." 

Dupuytren  says  :  "The  gravity  of  this  affection  (fissure)  depends 
chiefly  on  the  painful  spasm  of  the  sphincters  ;  the  fissure  is  only  an 
accident,  as  is  proved  by  the  existence  of  painful  spasm  without  fis- 
sure, which,  according  to  well-known  surgical  authorities,  is  found 
in  proportion  to  the  other  of  one  to  four."  And,  "  the  spasmodic 
constriction  is  the  true  lesion,  and  the  fissure  onlj^  an  epiphenome- 
non."     Sir  B.  Brodie  held  the  same  views. 


SPASM   OF   SPHINCTER  —  NEURALGIA.  389 

Symptoms. 

The  symptoms  of  spasm  of  the  sphincter  are  pain  on  defecation 
and  for  a  time  after ;  more  or  less  uneasiness  about  the  anus,  espe- 
cially when  sitting  ;  fulness  in  the  perineum  ;  often  more  or  less 
trouble  with  the  bladder,  as  shown  by  frequent  micturition,  some- 
times attended  by  smarting  in  the  urethra  and  constipation.  The 
disease  is  generally  attended  by  exacerbations  and  remissions.  A 
digital  examination  of  the  anus  is  always  painful,  and  the  contrac- 
tion may  be  so  great  as  to  leave  hardly  a  trace  of  the  anal  orifice.  Any 
anxiety  or  distress  of  mind,  a  generally  irritable,  nervous  condition, 
and  everything  which  has  a  tendency  to  irritate  the  rectum  or  the 
parts  around,  will  aggravate  the  complaint.  It  may  easil}^  be  con- 
founded with  the  affection  next  to  be  described,  neuralgia,  but  is 
generally  distinguishable  from  it  by  the  marked  dependence  of  the 
pain  upon  the  act  of  defecation,  which  is  not  seen  in  neuralgia  with- 
out spasm. 

The  treatment  consists  in  attention  to  the  general  health  of  the 
patient,  in  allaying  any  nervous  excitement,  in  the  administration 
of  a  cathartic  to  empty  the  bowel  when  the  spasm  is  present,  and  in 
anodyne  injections,  such  as,  for  example,  twenty  drops  of  laudanum 
in  an  ounce  of  water.  Suppositories  may  cause  renewed  irritation. 
Even  in  the  more  aggravated  form  the  disease  will  often  jdeld  to 
such  measures  as  this,  but  if  it  does  not  a  cure  may  always  be  ef- 
fected by  forcible  dilatation  of  the  sphincter  under  ether.  If  the 
patient  will  not  submit  to  this,  the  next  best  thing  will  be  found  to 
be  the  introduction  and  retention  of  a  bou2:ie. 


'&' 


Neuralgia. 

Neuralgia  of  the  rectum  is  generally  met  with  in  nervous  people, 
especially  females,  such  as  are  subject  to  neuralgia  in  other  parts  of 
the  body. 

In  some  persons  it  will  cause  the  same  suffering  as  the  most  in- 
tense neuralgia  elsewhere.  The  pain  is  apt  to  be  paroxysmal,  but 
may  be  continuous,  and  is  independent  of  the  act  of  defecation. 

In  cases  of  well-marked  periodicity  a  malarial  element  should  be 


390  SUKGERY   OF   THE   RECTUM   AND   PELVIS. 

looked  for,  and  the  disease  may  be  a  manifestation  of  the  gouty  di- 
athesis. In  the  former  case  quinine,  and  in  the  latter  colchlcum,  may 
be  of  the  greatest  service.  In  all  other  cases  the  treatment  will  often 
be  found  unsatisfactory,  and  is  to  be  conducted  on  general  princi- 
ples. The  first  care  should  be  for  the  general  health,  the  second  for 
the  regularity  of  the  bowels,  and,  after  this,  local  applications  of  cold 
water,  ointment  of  belladonna  (3  i.- 1  i.),  and  blistering  over  the  sa- 
crun^  may  be  tried.  Besides  this  local  treatment  the  case  must  be 
managed  exactly  as  would  be  a  case  of  neuralgia  in  any  other  part. 

The  diagnosis  from  coccygodynia  and  from  spasm  must  both  be 
made  with  care. 

I  have  come  to  be  very  cautious  as  to  the  diagnosis  of  pure  neu- 
ralgia of  the  rectum  without  first  making  a  careful  examination 
under  ether,  so  many  are  the  lesions  which,  though  difficult  to  detect 
and  slight  in  themselves,  may  cause  pain.  Those  most  frequently 
found  will  be  erosions  of  the  mucous  membrane,  and  small  internal 
fisculse. 


CHAPTER   XXI. 

SALPINGECTOMY  AND    OOPHORECTOMY  BY  ABDOMINAL    INCISION. 

It  is  not  too  much  to  say  that  the  mortality  of  these  operations 
will  depend  as  much  upon  the  technique  of  the  operation  itself  as 
upon  the  character  of  the  cases  operated  upon. 

In  simple  cases  without  pus  the  mortality  depends  almost  entirely 
upon  the  technique.  Pus  cases  will  occasionally  be  fatal,  in  spite  of 
every  precaution,  from  rapture  of  pus-tubes  or  ovaries,  or  from  rupt- 
ure of  extra-peritoneal  collections  of  pus  ;  but  they  will  generally  be 
fatal  in  the  hands  of  one  who  has  not  devoted  especial  study  to  the 
technique  of  pelvic  surgery. 

The  surgeon  may  be  forced  to  operate  in  the  most  unpromising 
case  to  save  life,  and  may  have  no  time  for  the  preparation  of  his 
patient ;  and  in  such  cases  the  mortality  will  be  great.  But  little 
value  is  therefore  to  be  attached  to  statistics  of  mortality  made  up 
without  regard  to  the  character  of  the  cases  operated  upon.  Given  a 
certain  class  of  simple  cases  and  a  clean  operator,  and  the  mortality 
may  easily  not  reach  over  two  or  three  per  cent ^  whereas  in  pus 
cases,  and  patients  in  bad  condition,  no  such  rate  can  be  expected  or 
hoped  for. 

Diagnosis. 

Perfect  accuracy  in  diagnosis  in  diseases  of  the  tubes  and  ovaries 
is  often  impossible  before  opening  the  abdomen,  and  death  may  re- 
sult from  rough  or  repeated  attempts  to  secure  it. 

Given  the  history  of  chronic  invalidism  from  pelvic  pain,  and  the 
presence  of  a  tumor  in  the  pelvis  be  made  out  by  conjoined  manipu- 
lation, an  operation  is  indicated,  whether  an  exact  diagnosis  between 


392  SUKGERY   OF   THE   RECTUM   AND   PELVIS. 

an  ovarian  and  tubal  abscess  can  be  made  or  not.  Many  cases  will 
be  doubtful,  even  with  the  tumor  in  the  hand  after  the  abdomen  has 
been  opened. 

Greater  judgment  may  be  shown  in  knowing  that  an  operation  is 
required  for  something  in  a  woman's  pelvis,  even  without  knowing 
exactly  what  that  something  is,  than  in  having  half  a  dozen  different 
men  examine  a  doubtful  case  before  operation,  at  the  imminent  risk 
of  rupturing  a  pus-sac  or  an  ectopic  pregnancy. 

The  most  perfect  accuracy  in  diagnosis  should  of  course  be  the 
life-long  study  of  the  operator,  and  the  man  who  approaches  most 
nearly  to  it  is  the  better  surgeon,  but  certainly  will  never  be  reached, 
nor  to  save  life  is  it  always  necessary,  while  the  attempt  to  reach  it 
may  end  fatally. 

Preparation  of  the  Patient. 

At  least  three  or  four  days  should  be  allowed  for  preparation  for 
an  abdominal  section.  If  the  patient  be  placed  in  a  hospital  this  is 
none  too  much  time  for  her  to  become  used  to  her  strange  surround- 
ings, and  it  may  be  well  spent  in  clearing  the  alimentary  canal. 

The  bowels  should  be  moved  freely  for  three  days  before  oper- 
ation by  laxatives  given  each  night.  Three  compound  cathartic 
pills  are  not  too  much  for  the  first  dose,  and  these  may  be  followed 
by  licorice  powder  -each  succeeding  evening,  and  an  enema  of  soap 
and  water  a  few  hours  before  the  operation. 

Although  nothing  but  milk  and  fluid  diet,  with  eggs,  should  be 
given  for  two  days  preceding  the  operation,  the  amount  of  nourish- 
ment should  not  be  restricted.  It  is  not  wise  to  starve  the  patient 
before  going  through  so  great  a  physical  trial,  and  personally  I  pre- 
fer that  my  patient  should  be  fed  in  the  way  mentioned  up  to  six 
hours  before  being  placed  upon  the  table. 

The  urine  should  be  drawn  or  passed  just  before  going  to  the 
operating-room. 

It  is  not  advisable  in  patients  of  delicate  nervous  susceptibilities 
to  spend  the  three  days  preparatory  to  the  operation  in  impressing 
upon  them  the  exact  point  at  which  they  are  to  be  cut  open  by  con- 
stantly scrubbing  and  poulticing  it.     Cheerfulness  should  be  culti- 


SALriNGECTOMY   AND   OOPHORECTOMY.  393 

vated,  and  this  can  hardly  be  cheerful,  nor  is  it  necessary.  All  final 
arrangements  can  be  made  while  the  patient  is  being  etherized,  and 
without  any  great  loss  of  time. 

The  nervous  condition  of  the  patient  is  always  worthy  of  atten- 
tion before  an  operation,  and  the  securing  of  sleep  is  very  important, 
even  by  resort  to  hypnotics  when  necessary.  In  many  of  these  cases 
the  action  of  the  heart  must  be  carefully  watched  and  a  hypodermic 
of  morphia  a  few  hours  before  being  placed  upon  the  table  will 
greatly  strengthen  the  pulse  and  lessen  the  nervous  shock  of  the 
ordeal. 


Operating  Table. 

This  should  be  preferablj^  with  a  glass  top,  so  made  as  to  allow  of 
the  draining  away  of  all  water  used  in  washing  the  patient  ;  and  the 
Trendelenberg  posture  may  be  indispensable  in  any  case,  even  chough 
the  operator  may  begin  without  the  intention  of  using  it.  Although 
most  operating-tables  are  now  made  for  the  express  purpose  of  allow- 
ing the  free  use  of  water  without  soaking  the  patient's  back,  it  is  as- 
tonishing how  often  this  provision  is  neglected. 

The  glass  top  is  usually  covered  with  a  sheet  folded  into  layers 
upon  which  the  patient  is  placed  before  she  is  washed  and  scrubbed, 
and  upon  which  she  remains  until  the  operation  is  completed.  In 
an  operation,  one  of  the  great  dangers  of  which  is  shock,  this  should 
be  avoided. 

Either  the  washing  should  be  done  with  no  cloth  under  the 
patient,  or  better,  a  dry  warm  sheet  should  be  substituted  for  the 
cold  wet  one  after  the  washing  is  finished.  This  may  seem  a  little 
matter,  but  nothing  which  tends  to  protect  the  patient  is  without  its 
influence  in  a  cceliotomy. 

The  assistants  necessary  for  comfortable  work  are  the  instrument 
tender,  the  etherizer,  one  to  directly  assist  at  the  wound;  one  to 
change  sponges,  and  one  to  handle  basins,  pitchers,  etc. 

For  directions  as  to  scrubbing  the  patient,  preparing  instruments, 
and  the  antiseptic  details  of  the  operation,  the  reader  is  referred  to 
the  chapter  devoted  to  these  subjects. 


394  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

The  instriiments  which  should  be  at  hand  for  every  coeliot- 
omy  are :  , 

Knife. 

Artery  forceps. 

Dissecting  forceps. 

Scissors  (straight  and  curved). 

Hagedorn  needles  (curved). 

Needle-holder. 

Sponge-holders. 

Sponges. 

Small  volsellum.  * 

Needles  for  intestinal  work. 

Fine  silk. 

Aspirator. 

Other  essentials,  such  as  gauze,  bandages,  adhesive  plaster,  towels, 
stimulants,  hypodermic,  etc.,  are  supposed  to  be  always  in  readiness. 

The  sponges  should  be  of  two  sizes,  small  ones  for  placing  in 
holders  and  using  deep  in  the  abdomen,  and  large  ones,  six  or  eight 
inches  square,  for  pressing  back  the  intestines  and  protecting  the 
abdomen,  and  these  should  be  carefully  counted,  and  the  number 
recorded,  before  the  operation  begins.  They  should  be  in  the  care  of 
one  special  assistant,  and  should  always  be  accounted  for  before 
closing  the  abdomen. 

It  is  an  awkward  thing  to  have  the  nurse  assert  that  a  sponge  is 
lost  just  as  the  final  dressings  are  being  put  on,  and  such  a  statement 
may  cost  the  patient  her  life,  be  it  true  or  false.  If  it  is  true,  the 
abdomen  must  be  reopened  and  it  must  be  searched.  If  it  is  false,  a 
still  longer  time  will  be  spent  searching  in  the  abdomen  for  it,  and 
the  search  may  just  turn  the  scale  against  the  patient.  I  have 
ventured  to  doubt  the  positive  statement  of  a  nurse  at  this  critical 
moment,  and  refused  to  reopen  an  abdomen  in  which  I  knew  no 
sponge  was  concealed,  although  one  was  missing ;  but  the  mistake 
should  not  occur,  and  will  not  if  the  sponges  are  taken  from  their  jar 
by  one  nurse,  counted  one  by  one  as  they  are  handed  to  another,  and 
the  number  written  down. 

A  safer  way  than  all  others,  however,  is  for  the  operator  never  to 
put  a  sponge  into  the  abdomen  without  leaving  a  pair  of  forceps 


SALPINGECTOMY   AND   OOPHORECTOMY.  395 

attached  to  it  hanging  oat  of  the  wound.  The  little  additional  trouble 
will  be  more  than  compensated  for. 

In  cases  of  suspected  pus-tubes  or  extra-uterine  pregnancy 
curetting  the  uterus  before  opening  the  abdomen  is  positively  contra- 
indicated,  and  may  be  fatal  from  rupture. 

When  all  is  ready,  the  incision  is  made  in  the  median  line,  or  to 
one  side,  as  is  preferred. 

There  is  an  idea  that  a  stronger  cicatrix  will  result  if  the  incision 
is  made  through  the  belly  of  the  rectus  than  if  made  in  the  median 
line  and  the  fibres  of  the  muscle  separated  without  cutting. 

The  incision  should  be  about  three  inches  long,  and  reach  to 
within  one  inch  of  the  symphysis  through  the  fat  and  the  fascia  of 
the  abdomen.  When  this  fascia  has  been  divided  the  knife  should 
be  turned  in  the  hand,  and  the  handle  used  to  separate  the  recti 
and  expose  the  peritoneum. 

The  peritoneum  should  be  grasped  between  two  pairs  of  dissect- 
ing forceps,  and  not  artery  forceps,  for  the  preliminary  incision  into  it. 
Artery  forceps  grasp  too  much  and  hold  what  they  grasp  too  firmly. 
Dissecting  forceps  are  more  delicate,  have  finer  points,  and  are  less 
liable  to  grasp  the  intestine.  It  is  an  easy  thing  to  seize  both  peri- 
toneum and  intestine  in  a  pair  of  artery  forceps  and  hold  them 
firmly,  and  the  intestine  may  be  wounded  in  this  way  in  the  attempt 
to  enter  the  peritoneum. 

The  incision  through  the  peritoneum  should  be  with  the  knife, 
and  the  moment  air  has  entered  the  cavity  the  intestine  will  fall 
away  from  the  incision  unless  it  is  adherent  at  that  point.  The  in- 
cision may  now  be  enlarged,  with  two  fingers  in  the  abdomen  for  a 
guide,  either  with  knife  or  scissors,  and  should  be  carried  down  as 
near  the  symphysis  as  possible  without  wounding  the  bladder,  for 
room  is  needed  at  the  lower,  and  not  at  the  upper  end  of  the  incision, 
for  working  in  the  pelvis,  and  an  inch  at  the  symphysis  is  worth 
several  at  the  umbilicus. 

The  next  step  is  the  careful  and  thorough  exploration  of  the  pel- 
vis with  two  fingers  in  the  incision. 

Often  an  indistinguishable  mass  will  be  encountered,  made  up  of 
uterus,  tubes,  ovaries,  pus-sacs,  and  adhesions  ;  or  the  disease  may 
be  comparatively  slight  and  the  organs  may  rest  in  their  proper  re- 


396  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

lations.  In  the  latter  case  the  operator  should  proceed  with  method 
and  deliberation. 

The  fundus  uteri  is  the  first  thing  to  be  sought  for,  and  from  this 
he  may  work  both  ways,  following  first  one  tube  out  to  its  ovary 
and  then  the  other,  bringing  the  parts  up  into  the  wound  and  exam- 
ining them  with  care. 

Should  an  ovary  be  found  cystic,  it  may  be  brought  out  of  the 
incision,  which  is  then  closed  by  slipping  a  sponge  into  it  under  the 
ovary  and  the  cyst  if  small  may  be  punctured  with  a  needle,  its  con- 
tents expressed,  and  the  ovary  returned.  Should  a  tube  be  in  com- 
paratively good  condition,  a  probe  may  be  passed  into  its  fimbriated 
extremity  down  to  the  uterine  cornu  to  test  its  permeability,  and  it 
may  be  returned.  Then  the  same  procedure  may  be  piacLised  on 
the  opposite  side. 

In  cases  of  slight  disease,  disease  which  has  rendered  the  woman 
miserable  but  does  not  justifj^  castration,  the  rule  is  to  save  the 
ovaries  whenever  possible,  and  to  save  a  part  of  one  ovary  even  when 
the  rest  has  to  be  sacrificed.  Conservative  surgery  means  more  here 
perhaps  than  in  any  other  part  of  the  body,  and  yet  it  may  be  carried 
too  far.  For  with  an  ovary  removed  the  corresponding  tube  is  only  a 
possible  focus  for  serious  disease,  and  with  both  ovaries  removed,  or 
both  tubes  diseased,  the  uterus  is  reduced  to  about  the  same  condition. 

Should  it  be  deemed  necessary  to  remove  a  tube  or  ovary,  or  both, 
it  is  well  to  bear  in  mind  the  fact  that  to  accomplish  this  safely  it  is 
not  at  all  necessary  to  surround  about  half  of  the  corresponding 
broad  ligament  with  a  heavy  silk  ligature  to  prevent  a  fatal  hemor- 
rhage. The  ovarian  artery  is  not  as  large  as  the  radial,  and  yet  from 
the  amount  of  violence  done  and  the  amount  of  force  used  to  secure 
any  possible  branch  from  it  before  cutting,  one  might  imagine  such 
to  be  the  case. 

Taking  the  broad  ligament  between  the  thumb  and  fingers  of  one 
hand  to  prevent  its  slipping  back  into  the  abdomen,  the  ovary  and 
tube  may  be  delicately  dissected  away  from  it  down  to  the  cornu  of 
the  uterus,  without  more  hemorrhage,  in  many  cases,  than  comes 
from  the  skin  incision,  or  more  than  can  be  controlled  with  a  single 
pair  of  artery  forceps.  But  a  small  bleeding  point  here  is  very  im- 
portant from  the  fact  that  the  stump  is  about  to  be  dropped  into  the 


SALPINGECTOMY    AND   OOPHORECTOMY.  397 

abdomen,  and  a  single  bleeding  vessel,  even  tliougli  small,  may  cost 
the  patient  her  life. 

Therefore,  great  care  should  be  used  in  operating  by  this  method, 
bleeding  points  should  be  secured  with  fine  catgut,  and  the  cut  edge 
of  the  broad  ligament  should  be  stitched  over  with  a  continuous  sut- 
ure of  the  same. 

The  advantage  of  this  method  of  operating  is,  that  besides  being 
more  surgical  in  that  it  is  better  adapted  to  the  desired  end,  it  leaves 
no  large  raw  stump-surface  to  be  subsequently  cared  for  by  nature 
after  the  abdomen  is  closed. 

Another  is  that  a  diseased  tube  may  be  dissected  out  close  up  to 
the  cornu  and  removed  in  its  entirety,  even  followed  a  little  into  the 
substance  of  the  uterus,  and  the  wound  in  the  uterus  closed  over  by 
a  few  stitches. 

It  is  believed  that  the  subsequent  pain  and  liability  to  adhesions 
is  much  less  by  this  method  of  removing  the  tubes  and  ovaries  than 
by  ligaturing  a  large  mass  of  tissue,  and  it  seems  only  probable  that 
such  should  be  the  case. 

In  these  cases  of  slight  disease  the  only  question  which  may  arise 
is  as  to  what  should  be  removed  and  what  allowed  to  remain,  and 
this  actually  hinges  upon  the  question  whether  the  organs  are  suf- 
ficiently diseased  so  that  they  can  no  longer  be  anything  but  a  source 
of  suffering  and  possible  danger ;  and  whether  pregnancy  is  apt  to 
occur  after  the  tapping  and  cleaning  out  of  a  small  cyst  of  the  ovary. 

Although  few  go  so  far  as  to  recommend  the  aspiration  of  a 
hydrosalpinx  and  leaving  the  tube,  or  even  excision  of  a  cyst  of  the 
tube  and  stitching  what  remains  to  the  ovary,  in  the  hope  of  a  future 
pregnancy,  it  certainly  seems  that  in  many  cases  cysts  may  be  re- 
moved from  the  ovary,  the  peritoneum  closed  over  the  wound,  and 
the  patient  left  in  much  better  condition  than  were  the  entire  ovary 
sacrificed.  Moreover  it  would  seem  probable  that  such  conservative 
surgery  might  bring  great  relief  to  symptoms. 

In  these  cases  there  need  be  very  little  toilet  of  the  peritoneum 
^fter  operation.  All  of  the  work  may  often  be  done  outside  of  the 
abdomen  with  the  organs  in  the  hand,  and  the  incision  closed  with  a 
sponge.  When  the  organs  have  been  returned  to  their  place,  a  small 
-sponge  held  in  a  sponge-holder  should  be  passed  into  Douglas's 


398  SUEGEEY   OF   THE   RECTUM   AND   PELVIS. 

pouch,  to  take  up  any  serum  that  may  have  collected  there,  and  the 
abdomen  may  be  closed. 

All  unnecessary  manipulation  within  the  abdomen  should  be 
scrupulously  avoided,  as  adding  to  the  shock  of  the  operation.  In 
the  majority  of  cases  it  will  not  be  necessary  at  any  time  to  intro- 
duce more  than  two  fingers  into  the  wound  in  order  to  hook  up  the- 
ovary  and  bring  it  out  of  the  incision,  with  its  corresponding  tube, 
even  when  numerous  but  slight  adhesions  exist.  In  this  way  there 
is  but  little  disturbance  of  the  intestines,  they  are  not  twisted  or 
bruised,  and  the  danger  of  consequent  kinking,  volvulus,  and  par- 
alysis are  reduced  to  a  minimum. 

There  should  be  no  irrigation  of  the  abdomen  after  such  an  oper- 
ation, as  there  is  nothing  to  be  washed  out. 

In  cases  where,  on  account  of  soiling  the  peritoneum  by  fluids- 
which  have  escaped  from  the  tubes  or  ovaries  during  the  operation, 
it  is  necessary  to  take  every  precaution  against  septic  peritonitis,  a 
question  will  often  arise  as  to  whether  the  abdomen  should  be  irri- 
gated, or  drained  without  irrigation,  or  whether  both  should  be  used. 

If  irrigation  be  employed  it  should  unquestionably  be  very  free, 
and  it  should  never  be  done  in  the  Trendelenberg  posture.  If  pus  is 
to  be  washed  out  in  this  way,  it  need  not  be  allowed  to  flow  b}^  grav- 
ity up  to  the  diaphragm,  and  it  should  be  diluted  as  much  as  pos- 
sible. 

The  best  material  for  irrigation  is  hot  sterilized  water.  No  chem- 
ical antiseptic  should  be  used.  Hot  saline  solution  may  also  be  used 
if  the  operator  prefers.  Two  Angers  should  press  the  uterus  toward 
the  symphysis  and  hold  it  there  so  that  the  fluid  may  flow  readil}^ 
into  Douglas's  pouch  and  escape,  and  a  considerable  quantity  may  be- 
left  in  the  abdomen  with  advantage  after  the  irrigation  is  completed. 
It  is  quicklj^  absorbed  after  the  wound  is  closed,  and  it  may  have  an 
effect  in  diminishing  the  thirst  which  always  follows  an  abdominal 
section,  as  well  as  in  preventing  adhesions  of  the  intestines. 

In  cases  where  there  has  been  pelvic  inflammation  and  in  which 
all  of  the  organs  are  matted  together  by  plastic  exudation,  or  in 
which  the  intestine  or  omentum  is  bound  to  the  uterus  or  adnexa  by 
adhesions  more  or  less  firm,  the  operation  becomes  a  very  difficult  one. 

From  the  time  the  peritoneum  is  first  nicked  the  operator  may 


SALPINGECTOMY   AND   OOPHORECTOMY.  399 

find  himself  in  trouble.  Omentum  may  completely  conceal  the  site 
of  the  operation,  and  this  must  first  be  torn  loose  and  pressed  up  into 
the  abdomen.  Hemorrhage  from  the  omental  vessels  must  be  care- 
fully guarded  against,  and  too  much  omentum  must  not  be  included 
in  a  single  ligature  lest  secondary  bleeding  occur.  Where  much 
omentum  is  to  be  tied  off,  the  chain  ligature  is  the  best  form. 

Adherent  intestine  is  more  difficult  to  manage  than  omentum,  as 
force  cannot  be  used  to  tear  it  loose,  and  unless  the  adhesions  yield 
easily  to  pressure  of  the  end  of  the  finger  a  tedious  dissection  is 
necessary.  This  may  generally  be  done  with  the  handle  of  the  knife, 
but  occasionally  a  little  cutting  with  the  scissors  will  save  the  gut 
from  being  torn,  and  a  good  view  of  the  pelvis  is  absolutely  essential. 

Retractors  here  come  into  use,  and  the  best,  because  they  take  up 
no  room,  are  two  strong  ligatures  passed  through  the  fascia  of  the 
abdomen,  one  on  each  side  of  the  incision. 

When  intestine  is  injured  beyond  the  peritoneal  coat  in  this  dis- 
section it  must  be  repaired  with  Lembert's  sutures  before  the  opera- 
tion is  continued,  and  the  means  for  doing  so  should  always  be  among 
the  instruments  provided  for  the  operation.  Should  actual  rupture 
of  the  gut  be  caused  which  is  beyond  the  reach  of  repair  by  a  back- 
to-back  approximation  of  the  rent,  an  intestinal  anastomosis  must 
be  done ;  and  this  should  be  preferably  by  some  variety  of  suture 
(Abbe's,  Maunsell's,  or  end  to  end)  rather  than  by  the  Murphy 
button. 

Having  freed  omentum,  intestine,  and  bladder  from  the  pelvic 
mass,  the  operator  may  proceed  with  the  enucleation,  having  now 
nothing  to  fear  except  the  large  vessels  and  the  ureters,  both  of 
which  have  been  ruptured,  the  latter  many  times. 

The  secret  of  safety  and  rapidity  in  enucleating  such  a  mass  will 
be  found  in  working  with  the  fingers  as  near  to  the  mass  as  possible, 
and  in  first  finding  some  weak  point  between  it  and  the  sacrum  which 
may  be  taken  advantage  of  for  a  commencement,  and  from  which 
progress  may  be  made  in  all  directions. 

The  most  essential  point  at  this  stage  of  the  operation  is  to  avoid 
in  every  possible  way  the  rupture  of  pus-sacs.  This  may  be  done  by 
gentleness  in  many  cases,  but  not  in  all.  Pus  may  be  encountered 
at  any  moment  before  either  tube  or  ovary  has  been  sufficiently 


400  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

loosened  from  the  general  mass  to  be  recognized.  When  such  is  the 
case,  the  only  safeguard  possible  for  the  patient  is  to  have  the  parts 
well  protected  by  sponges,  and  to  wipe  up  the  pus  as  it  escapes  as 
rapidly  as  possible  with  pieces  of  dry  gauze,  which  are  thrown  away 
as  used.  It  is  well  to  remember  that  the  presence  of  pus  may  mean 
the  death  of  the  patient  from  septic  peritonitis,  and  act  with  corre- 
sponding caution. 

Masses  containing  fluid  in  such  cases  may  often  be  aspirated  with 
advantage  before  any  force  is  used  in  enucleating  them,  and  an 
aspirator  should  also  always  be  in  readiness.  After  pus  has  been 
drawn  off,  the  aspirator  puncture  may  be  closed  by  a  stitch  or  two 
through  the  wall  of  the  sac,  and  the  danger  of  subsequent  rupture 
by  manipulation  will  be  much  lessened  by  the  relief  of  tension. 

As  soon  as  the  fundus  uteri  has  been  recognized,  a  great  point 
has  been  gained  in  that  the  operator  has  a  sure  guide  to  the  tubes 
and  thence  to  the  ovaries.  First  one  ovary  may  be  gently  worked 
up  from  behind  the  broad  ligament  and  then  the  other.  It  will  not 
be  possible  as  a  general  rule  to  bring  one  tube  and  ovary  outside  the 
abdomen  while  the  other  is  still  bound  down  ;  but  one  side  may  be 
tied  off  within  the  pelvis  before  the  other  is  attacked,  and  where  pus 
is  suspected  in  the  liberated  side,  this  is  a  good  rule  to  follow. 

Many  forms  of  ligatures  and  knots  are  in  use,  but  none  is  better 
than  a  double  interlocked  ligature  of  strong  catgut,  passed  through 
the  broad  ligament  with  a  Cleveland  ligature  carrier,  or  with  a 
large  curved  needle.  The  ligature  should  be  at  least  one  metre  long 
before  it  is  divided  after  being  passed,  so  that  when  cut  in  two  each 
half  will  be  long  enough  for  the  operator  to  secure  a  good  hold  in 
tying.  The  two  ligatures  are  then  twisted  together  so  that  when 
one  is  tied  around  one  side  of  the  mass  to  be  removed,  the  middle  of 
the  other  is  in  its  grasp.  The  second  is  then  also  tied  around  the 
other  half  of  the  pedicle,  and  a  figure-of-eight  loop  is  the  result. 

Before  tying  the  final  ligature,  tension  upon  the  broad  ligament 
should  be  relaxed  in  order  that  there  may  be  less  retraction  of  the 
stump  after  the  mass  has  been  cut  away,  as  this  retraction  when  the 
tension  has  been  great  may  cause  the  stump  to  escape  from  its 
ligature.  If  the  round  ligament  is  included  in  the  ligature  there 
will  be  less  danger  of  slipping. 


SALPINGECTOMY   AND   OOPHOKECTOMT.  401 

Medium  strong  catgut  answers  every  purpose  for  the  ligature, 
and  unnecessarily  heavy  gut  or  silk  is  often  used.  When  once  a 
surgeon  is  convinced  of  the  reliability  of  his  own  catgut,  as  prepared 
by  himself,  he  will  seldom  use  any  other  material  in  an  abdominal 
operation. 

The  stump  will  contain  the  cut  end  of  the  Fallopian  tube,  and  as 
this  cut  surface  is  in  all  probability  septic,  it  should  be  cauterized 
with  pure  carbolic  acid  on  a  piece  of  cotton  held  in  forceps  before 
being  dropped  into  the  pelvis.  The  entire  tube,  close  to  the  cornu  of 
the  uterus,  should  be  removed. 

Having  removed  the  tube  and  ovary  on  one  side,  the  other  may 
be  enucleated  in  the  same  way,  and  the  question  as  to  whether  the 
uterus  should  be  saved  or  removed  may  be  considered. 

In  some  cases  the  uterus  will  be  so  manifestly  diseased,  and  the 
presence  of  pus  in  its  substance  in  small  foci  so  palpable,  that  com- 
plete hysterectomy  offers  the  only  chance  for  curing  the  patient. 
Generally,  however,  future  curettage  may  be  counted  upon  to  cure 
the  disease  of  the  uterine  mucosa. 

A  more  delicate  question  to  decide  is,  what  to  do  with  a  healthy 
tube  on  one  side  when  the  other  is  purulent,  but  the  consensus  of 
opinion  is  in  favor  of  giving  the  patient  a  chance  of  pregnancy, 
trusting  to  future  curettage,  even  should  a  second  opening  of  the 
abdomen  be  necessary. 

Should  the  uterus  prove  a  source  of  t-rouble  after  both  adnexa 
have  been  removed,  and  resist  treatment,  a  vaginal  hysterectomy 
can  be  done  with  greater  ease  than  an  abdominal  one  at  the  time  of 
the  removal  of  the  tubes  and  ovaries. 

The  toilet  of  the  peritoneum  should  next  be  considered,  and 
should  pus  have  escaped  during  the  operation  this  is  a  matter  of 
the  greatest  importance.  As  much  fluid  as  possible  should  be  re- 
moved with  sponges,  as  in  this  way  it  is  not  scattered  over  the  intes- 
tines. The  table  should  next  be  lowered  from  the  Trendelenberg 
position  and  hot  water  freely  used  for  irrigation.  x\f ter  this  drainage 
should  never  be  neglected,  and  this  should  preferably  be  with  two 
strips  of  gauze,  one  passing  into  the  pouch  of  Douglas  from  the  in- 
cision, and  the  other  from  the  pouch  into  the  vagina. 

The  best  way  to  accomplish  this  is  to  lay  a  long  strip  of  gauze  in 

26 


402  SUEGERY   OF   THE   RECTUM   AND   PELVIS. 

Douglas's  poucli  and  then  close  the  abdomen,  after  providing  a  sec- 
ond independent  gauze  drainage  through  the  abdominal  incision. 
After  the  abdomen  is  closed  the  position  of  the  patient  is  changed, 
the  vagina  is  opened  posteriorly,  the  strip  of  gauze  left  in  Douglas's 
pouch  is  seized  with  dressing  forceps,  and  pulled  out  through  the 
vulva. 

Another  method  is  the  same,  with  the  exception  of  the  vaginal  in- 
cision and  drainage  into  that  canal.  A  large  square  piece  of  gauze 
may  be  placed  in  Douglas's  pouch  in  the  form  of  a  bag,  with  the 
edges  brought  out  at  the  abdominal  incision,  and  into  this  several 
strips  of  gauze  may  be  packed,  with  one  end  left  protruding  from 
the  mouth  of  the  bag.  These  may  be  removed  one  by  one,  and  the 
bag  itself  will  come  out  easily  after  the  strips  have  been  removed. 

A  good  drain  is  made  by  wrapping  a  roll  of  gauze  in  a  layer  of 
rubber  tissue,  cutting  off  the  ends  to  the  desired  length,  and  cutting 
fenestra  in  the  sides.  It  drains  as  well  as  a  glass  tube,  is  less  dan- 
gerous to  the  intestines,  and  is  more  easily  removed  than  gauze,  be- 
cause it  does  not  so  firmly  unite  to  the  intestines  by  adhesions.  A 
large-sized  rubber  drainage-tube  with  side  fenestra  also  answers 
every  purpose. 

In  cysts  containing  pus,  where  the  condition  of  the  patient  will  not 
permit  of  completing  the  operation  of  removal  of  the  cyst  after  the 
evacuation  of  its  contents,  the  cyst  wall  should  be  stitched  in  the 
lower  end  of  the  abdominal  incision  and  drained.  Fig.  209  repre- 
sents a  very  large  suppurating  dermoid  cyst  which  was  ruptured 
very  early  in  the  operation  for  removal,  flooding  the  abdomen  with 
pus  while  in  the  Trendelenburg  posture.  The  patient  being  in  very 
poor  condition  before  being  placed  on  the  table,  no  attempt  was 
made  at  enucleation.  The  abdomen  was  flushed  with  warm  saline, 
and  the  cyst  itself  was  cleaned  of  its  solid  contents  with  the  hand, 
and  also  thoroughly  washed.  A  gauze  drain  was  left  in  the  perito- 
neum, the  cyst  was  packed  with  gauze,  stitched  to  the  abdominal 
incision,  and  a  separate  piece  of  gauze  introduced  into  the  sac 
through  this  incision.  Posterior  colpotomy  was  then  performed,  and 
the  gauze  from  the  peritoneum  and  that  contained  in  the  sac  both 
pulled  into  the  vagina.  The  patient  escaped  all  septic  poisoning, 
and  made  a  good  recovery. 


SALPINGECTOMY   AND   OOPHOKECTOMY. 


403 


Fig.  209. 
Large  Suppurating  Dermoid  Cyst.     (Personal.) 


404  SUEGEEY  OF  THE  EECTUM  AND  PELVIS. 

Such  an  operation  involves  the  subsequent  removal  of  the  cyst,  if 
the  case  requires  it,  after  the  patient  has  improved  sufficiently  in  gen- 
eral condition. 

The  drainage  should  be  kept  up  till  the  patient's  temperature 
shows  her  to  be  out  of  danger  of  septic  poisoning. 

Hemorrliage. 

The  most  troublesome  source  of  bleeding  is  apt  to  be  from  firm 
and  old  adhesions  which  have  been  torn  loose  in  the  operation.  Often 
when  the  operator  is  ready  to  close  the  abdomen  he  will  be  afi-aid  to 
do  so  because  fresh  blood  is  constant!}^  oozing  and  filling  Douglas's 
pouch.  It  is  true  that  such  bleeding  will  often  cease  spontaneously 
after  the  abdomen  is  closed,  but  it  may  not,  and  tlie  wound  may 
have  to  be  reopened  on  that  account. 

In  such  a  case,  unless  a  stitch  can  be  passed  under  the  bleeding 
point  to  secure  it,  there  is  nothing  to  be  done  but  pack  the  abdomen 
at  the  site  of  the  oozing.  This  should  be  done  with  a  single  long 
strip  of  gauze,  whicli  may  be  removed  at  the  end  of  forty-eight  hours. 

Closure  of  the  Wound. 

The  strongest  possible  method  of  suture  of  an  abdominal  wound 
is  a  matter  about  which  there  are  many  different  opinions,  some 
preferring  a  number  of  interrupted  sutures  of  silk- worm  gut  passed 
through  the  whole  thickness  of  the  abdominal  wall  ;  others,  several 
TOWS  of  continuous  sutures  of  catgut  by  which  homologous  struct- 
iires  are  united  layer  by  layer  ;  and  others  still,  a  combination  of  the 
two  methods. 

The  great  desideratum  is  that  muscle  should  be  brought  into  ap- 
position with  muscle,  and  fascia  with  fascia,  and  there  would  seem 
little  doubt  that  this  can  be  more  accurately  accomplished  by  special 
rows  of  sutures  than  by  a  single  interrupted  one,  no  matter  how 
strong  it  may  be  in  itself,  by  which  all  the  layers  are  brought  into 
contact  en  masse. 

Much  will  depend  upon  the  surgeon's  confidence  in  his  own  cat- 
gut. If  he  is  using  gut  which  has  been  chromicized  to  last  and  resist 
absorption  for  three  or  six  weeks,  and  if  the  gut  has  been  prepared 


SALPINGECTOMY   AND   OOPHORECTOMY.  405 

and  tested  by  himself,  he  will  have  no  fear  of  failing  to  secure  a 
hard,  firm  cicatrix.     Such  gut  need  not  be  large  to  be  safe. 

A  continuous  suture  of  rather  small  gut  should  be  used  for  the 
peritoneum,  and  after  running  frorn  the  top  to  the  bottom  of  the  in- 
cision, the  same  may  be  used  to  return  in  the  muscular  layer  from 
bottom  to  top  without  interruption.  In  this  way  one  knot  is  avoided 
and  as  few  knots  should  be  concealed  in  the  wound  as  possible.  A 
stronger  suture  should  then  be  used  to  bring  together  the  fascia,  and 
this  being  heavier  than  is  needed  for  the  skin,  should  be  tied  and  cut. 
A  third  suture  of  fine  gut  finally  unites  the  skin  margins. 

The  avoidance  of  an  unsightly  scar  is  always  a  desideratum,  and 
fine  needles,  fine  gut,  and  accurate  coaptation  of  the  skin  are  all 
essential.  Before  tying  the  skin  suture,  all  air  and  fluids  should  be 
pressed  out  of  the  incision. 

A  very  pretty  way  of  giving  a  light  linear  skin  cicatrix  is  not  to 
perforate  the  skin  at  any  point  with  the  needle,  but  to  keep  the 
suture  entirely  wdthin  the  substance  of  the  skin  margin.  This  may 
be  easily  done  by  commencing  at  one  end  and  passing  the  suture 
through  about  half  an  inch  of  the  cut  margin  of  the  skin  of  one  flap, 
then  crossing  to  the  other  flap,  and  taking  half  an  inch  of  that,  then 
back  to  the  first  for  another  stitch,  and  so  back  and  forth  till  the 
other  end  is  reached.  No  knot  has  been  made,  and  when  the  two 
ends  of  the  running  suture  are  pulled  upon  a  very  accurate  coapta- 
tion will  result,  with  the  suture  entirely  buried  in  the  skin  itself. 
This  is  maintained  by  simply  tying  the  two  ends,  one  from  the  upper 
and  the  other  from  the  lower  angle  together,  and  the  resulting  scar 
will  be  a  mere  line. 

Dressings. 

The  incision  should  be  covered  with  sterilized  gauze  in  two  or 
three  layers.  The  first  layer  simply  covers  the  incision,  the  others 
are  larger  and  cover  the  abdomen.  These  are  retained  by  broad 
bands  of  adhesive  plaster. 

If  the  patient  does  well  this  dressing  should  not  be  removed  for  a 
week.  At  the  end  of  that  time  it  should  be  removed,  the  wound  ex- 
amined for  stitch  abscesses,  and  if  found  in  good  condition  a  similar 
dressing  should  be  applied  and  left  on  for  another  week. 


406  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

Some  operators  prefer  to  dust  the  incision  with  aristol  or  iodoform 
before  applying  the  dressing,  but  this  is  a  matter  of  individual  taste, 
and  not  a  requisite  to  primary  union. 

Effects  of  Remomng  the  Ovaries. 

On  this  point  the  operator  must  be  prepared  to  answer  man}'' 
questions  and  combat  many  popular  ideas,  such  as  that  the  operation 
will  cause  the  patient  to  grow  fat,  or  to  develop  a  beard ;  that  sexual 
appetite  will  be  entirely  lost,  and  the  voice  become  masculine. 

The  effect  of  the  operation  is  twofold :  first,  to  cure  the  patient  of 
her  disease  and  to  restore  her  to  health  ;  second,  to  bring  about  the 
change  of  life  ;  and  the  changes  in  the  woman  will  be  such  as  natu- 
rally follow  these  two  things  in  any  woman. 

The  menopause  in  itself  coming  on  naturally  seems  to  make  no 
change  in  the  sexual  appetite,  and  the  same  is  true  of  the  results  of 
an  operation.  The  patient. may  therefore  be  assured  that  she  will  be 
exactly  like  all  other  women  who  have  passed  the  change  of  life, 
plus  the  fact  that  she  will  have  some  chance  of  being  cured  of  a  dis- 
ease which  is  rendering  her  life  miserable,  and  which  can  be  cured  in 
no  other  way. 

There  is  almost  invariably  a  menstrual  flow  immediately  after  the 
operation,  and  in  quite  a  percentage  of  cases  (ten)  menstruation  goes 
on  after  the  operation  as  before. 

Unfortunately,  too  much  immediate  relief  from  pain  must  not  be 
promised,  for  this  is  the  exception.  In  time  perfect  health  may  be 
restored,  but  generally  not  till  after  many  months.  Every  such 
operation  may  be  followed  by  adhesions  which  will  give  trouble,  and 
in  many,  although  pus-tubes  and  ovaries  have  been  successfully 
removed,  there  will  still  remain  sufficient  inflammatory  trouble  to  be 
a  cause  of  suffering. 

After-treatment  of  Laparotomies. 

In  the  after-treatment  of  abdominal  sections  there  are  some  gen- 
eral rules  to  be  followed  in  all  cases,  and  some  which  apply  chiefly 
to  intestinal  work. 

In  other  words,  the  rules  for  the  management  of  the  bowels  after 


SALPINGECTOMY   AND   OOPHORECTOMY.  407 

a  laparotomy  for  disease  of  the  uterus  or  adnexa,  are  not  in  all  re- 
spects the  same  as  those  which  apply  to  a  case  of  intestinal  anasto- 
mosis. In  the  one  case  the  bowel  is  a  perfect  canal  which  need  only 
be  forced  to  do  its  work  ;  in  the  other  it  is  a  wounded  and  enfeebled 
organ  which  needs  especial  care. 

It  thus  happens  that  in  some  cases  where  it  is  most  desirable  that 
the  bowel  should  be  made  to  act,  we  are  restrained  from  the  admin- 
istration of  purgatives  for  several  days. 

The  complications  most  to  be  dreaded  after  laparotomy  for  any 
cause  are  : 

Hemorrhage. 

Shock. 

Vomiting. 

Intestinal  paralysis. 

Volvulus. 

Sepsis. 

Hemorrhage  is  shown  by  a  gradually  failing  pulse,  beginning 
some  time  after  the  patient  has  been  put  to  bed.  Should  the  shock 
have  been  so  great  as  to  leave  the  patient  almost  pulseless  when  the 
operation  is  completed,  a  subsequent  hemorrhage  added  to  the 
shock  may  be  indistinguishable  from  the  shock  of  the  operation. 
So  closely  do  the  symptoms  resemble  each  other  that  the  only  way 
of  distinguishing  between  them  may  be  by  the  time  of  their  appear- 
ance. 

On  the  other  hand,  should  the  patient  have  rallied  nicely  from 
the  operation  and  have  a  fairly  strong  pulse  for  some  hours,  and 
should  the  pulse  then  begin  gradually  to  fail,  hemorrhage  may  be 
counted  upon  as  the  cause  of  the  condition,  and  the  only  treatment 
Is  to  open  the  wound  and  secure  the  bleeding  point. 

ShocJc. 

This  attends  all  laparotomies  to  a  greater  or  less  degree,  and 
may  be  shown  by  coldness  of  the  extremities,  clammy  sweat,  and 
feeble  pulse  at  the  completion  of  the  operation.  It  is  to  be  met 
by  hot  applications  to  the  body  (hot  sheets  and  bottles),  injections 
of  strychnia,  gr.  -^V,  every  hour  or  half  hour,  and  brandy  with 
ammonia  by  the  mouth. 


408  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

Vomiting. 

Having  carried  the  patient  safely  through  the  complications  of 
shock  and  hemorrhage,  the  condition  of  the  stomach  and  bowels  is^ 
to  be  carefully  noted  and  treated. 

Some  vomiting  from  the  ether  is  to  be  expected,  but  this  should 
not  last  longer  than  tv/elve  hours.  During  this  time  food  should  be 
absolutely  abstained  from,  the  dryness  of  the  mouth  is  to  be  over- 
come by  washing  the  lips,  teeth,  and  tongue  with  a  cloth  wrung  out  in 
hot  water,  and  the  thirst  is  to  be  treated  by  teaspoonful  doses  of  hot 
water  every  hour.  If  after  twelve  hours  the  stomach  has  become 
quiet,  the  administration  of  food  may  be  begun,  and  this  should  vary 
according  to  the  operation. 

Should  the  alimentary  canal  be  uninjured,  small  doses  either  of 
milk  or  beef-soup  may  be  given — an  ounce  every  two  hours.  On  the 
other  hand,  should  the  operation  have  been  upon  the  alimentary 
canal,  milk  should  not  be  given,  and  the  food  should  be  limited  to 
beef-soup.  Milk  causes  large  passages,  which  are  contra-indicated  in 
operations  on  the  intestines,  and  also  in  some  patients  flatulence. 

In  all  cases  in  which  milk  is  given,  it  should  either  be  predigested 
or  mixed  with  lime-water  in  the  proportion  of  three  to  one. 

Nourishment  is  of  the  greatest  possible  importance,  and,  unless 
the  lower  bowel  has  been  operated  upon  or  injured,  nutritive  enemata 
should  never  be  neglected  where  the  stomach  rejects  food. 

Intestinal  Paralysis. 

This  will  show  itself  first  by  flatulence  and  consequent  distention 
of  the  abdomen.  It  is  always  a  bad  sign  and  must  be  overcome  if 
the  patient  is  to  be  saved.  When  it  appears  to  any  marked  extent, 
no  matter  whether  on  the  flrst,  second,  or  third  day,  purgatives 
should  at  once  be  given  by  the  mouth,  if  the  stomach  is  in  condition 
to  bear  them,  or  by  enema  with  the  long  tube  if  the  stomach  be  not 
in  condition  to  act. 

Should  administration  by  the  mouth  be  chosen,  small  doses  of 
calomel,  frequently  repeated  and  given  dry  upon  the  tongue,  are  the 
most  reliable,  as  they  cannot  be  vomited.     Enemata  with  the  long 


SALPINGECTOMY   AND   OOPHORECTOMY.  409^ 

tube  (given  by  one  who  can  introduce  a  long  tube)  are  of  great  value,, 
and  the  enema  should  be  medicinal  as  well  as  mechanical.  A  good 
formula  is  half  an  ounce  of  epsom  salts,  half  an  ounce  of  turpentine, 
and  a  quart  of  water. 

The  use  of  the  long  tube  merely  as  a  mechanical  outlet  for  gas  is 
to  my  mind  a  useless  torture  of  the  patient.  Unless  the  bowel  can 
be  stimulated  to  peristaltic  action,  neither  a  tube  in  the  rectum  nor 
an  enterostomy  will  do  more  than  evacuate  the  gas  in  its  immediate 
vicinity. 

The  passage  of  a  long  tube,  eighteen  or  twenty -four  inches,  into 
the  descending  colon  requires  more  skill  than  the  average  nurse  pos- 
sesses. It  can  seldom  be  done  without  the  aid  of  fluid  to  distend 
the  upper  rectum  and  sigmoid. 

The  patient  should  be  placed  on  the  side,  preferably  the  left,  and 
brought  well  to  the  edge  of  the  bed.  The  tube,  a  soft  one,  should 
be  well  oiled  its  entire  length,  and  inserted  into  the  anus.  After  it 
has  been  passed  about  six  inches  it  will  almost  invariably  be  stopped 
by  the  promontory  of  the  sacrum  or  by  a  fold  of  mucous  membrane^ 
and  the  nurse,  unable  to  insert  it  farther,  proceeds  with  the  injection 
which  never  reaches  above  the  rectal  pouch. 

The  sepret  of  success  lies  in  repeating  the  effort  to  introduce  the 
tube  higher  while  the  first  four  or  six  ounces  of  fluid  are  being  in- 
jected. The  fluid  distends  the  rectum,  smooths  out  the  folds  of  mu- 
cous membrane,  and  gentle  pressure  on  the  tube  will  do  the  rest.  In 
this  way  a  tube  can  generally  be  passed  eighteen  inches  without  dis- 
turbing the  patient,  and  the  balance  of  the  enema  may  then  be  in- 
jected. 

Vol'oulus. 

Obstruction  of  the  intestine  from  paralysis  may  be  indistinguish- 
able from  volvulus  or  kinking,  but  if  the  latter  is  diagnosticated  the 
abdomen  must  be  reopened  and  search  made  for  it.  This  adds 
greatly  to  the  patient's  risk,  it  is  true,  but  there  is  nothing  else  to  be 
done. 

The  fact  that  a  small  amount  of  fecal  matter  has  been  passed 
by  the  aid  of  enemata  does  not  prove  that  volvulus  ma,y  not  be  pres- 
ent, for  such  an  amount  of  fseces  may  simply  be  washed  out  of  the 


410  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

rectum.  The  only  reliable  sign  of  intestinal  obstruction  is  disten- 
tion of  the  abdomen,  and  unless  this  can  be  reduced  by  the  evacu- 
ation of  wind,  and  fecal  matter  induced  by  catharsis  and  enemata, 
reopening  the  incision  is  justifiable. 

Sepsis. 

After  laparotomy,  sepsis  may  show  itself  in  several  ways.  Par- 
alysis of  the  intestine,  just  spoken  of,  may  be  one.  Stead}^  rise  of 
pulse  and  temperature  is  another ;  vomiting,  profuse  sweating,  and 
delirium  are  others. 

To  combat  this  condition  the  surgeon  is  comparatively  powerless, 
the  only  reliable  means  in  his  power  being  the  free  administration  of 
purgatives.  If  the  bowels  can  be  induced  to  act  (and  every  effort 
should  be  used  even  to  the  administration  of  croton  oil),  the  patient 
may  be  saved  ;  for  experience  has  proved  that  free  catharsis  is  the 
greatest  safeguard  against  sepsis  after  laparotomy.  But  should  the 
administration  of  cathartics  be  ineffectual,  the  patient's  end  is  near. 

A  slight  degree  of  septic  poisoning  may  be  overcome  by  purgation. 
A  septic  inflammation  of  the  peritoneum  is  invariably  fatal. 

In  operations  upon  the  alimentary  canal,  should  the  patient  be 
doing  well  as  regards  food  and  sepsis,  a  movement  of  the  bowels 
should  be  delayed  as  long  as  possible,  and  then  soft  movements 
should  be  encouraged  by  the  administration  of  salines,  and  once 
established  should  be  kept  up  from  day  to  day.  In  this  way  the 
bowel  is  given  a  chance  to  heal  soundly  after  the  operation. 

The  fashion  of  the  day  is  entirely  against  the  use  of  opium  after 
laparotomies,  and  in  favor  of  free  catharsis  as  soon  as  possible.  How 
long  that  fashion  will  last  remains  to  be  seen.  The  amount  of  com- 
fort to  the  patient  which  an  occasional  hypodermic  of  morphia  will 
give,  the  strengthening  effect  upon  the  pulse  which  it  will  exercise, 
and  its  value  as  a  substitute  for  food,  are  all  well  known,  and  not 
long  ago  were  gladly  taken  advantage  of .   . 


CHAPTER  XXII. 

OPERATIONS   ON   THE    VAGINA. 

Laceration  of  the  Sphincters  and  Proctocele. 

Although  the  rectum  may  be  torn  by  direct  injury,  tlie  intro- 
duction of  foreign  bodies,  etc.,  by  far  the  most  frequent  cause  of 
laceration  is  parturition. 

Such  lacerations  may  be  slight,  involving  only  the  floor  of  the 
vagina  and  the  perineum,  or  they  may  extend  completely  through 
the  sphincters  and  the  whole  length  of  the  recto-vaginal  septum,  so 
that  rectum  and  vagina  are  converted  into  one  common  cavity. 

When  left  to  their  natural  consequences  they  produce  a  train  of 
anatomical  changes  in  the  parts,  and  consequent  symptoms,  which 
are  only  curable  by  surgical  methods. 

The  changes  which  follow  naturally  upon  a  laceration  of  the  peri- 
neum are  proctocele,  cystocele,  and  prolapsus  of  the  uterus.  The 
symptoms  complained  of  by  these  patients  may  be  leucorrhoea,  pain 
in  the  back,  dragging  sensations  in  the  pelvis,  and  a  feeling  of  pro- 
trusion and  dropping  of  the  pelvic  organs  ;  in  which  case  they  will 
generally  consult  a  gynaecologist  ;  or,  on  the  other  hand,  the  rectal 
symptoms  may  entirely  overshadow  the  others  and  they  may  com- 
plain of  nothing  bat  an  obstinate  and  incurable  difficulty  in  defeca- 
tion or  of  loss  of  control  over  the  sphincters. 

In  describing  the  difficulty  in  defecation  they  will  explain  that 
the  more  they  strain  the  worse  they  are  (and,  indeed,  such  is  the  case, 
as  the  straining  tends  very  directly  to  aggravate  the  condition) ;  and 
will  describe  how  the  fasces  bulge  into  the  vagina  as  though  they 
would  escape  through  the  vulva,  or  how  the  rectum  is  absolutely 
closed  in  the  act  of  defecation  by  the  descent  of  the  uterus. 


412 


SURGERY   OF   THE   RECTUM   AND   PELVIS. 


Some  will  say  that  it  is  only  possible  to  empty  the  rectum  by 
placing  two  fingers  into  the  vagina  and  pressing  the  fecal  mass  back- 
wards and  out  of  the  rectum.  This  is  because  the  vaginal  outlet  and 
the  recto-vaginal  septum  have  become  so  relaxed  as  to  permit  bulging 
of  the  rectal  wall  into  the  vagina  ;  or  proctocele,  the  sphincter  ani 


Fig.  210. 
Complete  Laceration. 


still  retaining  its  power,  while  that  of  the  levator,  whose  function  it 
is  to  close  the  vagina  and  thus  counteract  the  sphincter,  is  lost  from 
rupture  of  its  fibres. 

Following  the  formation  of  a  proctocele  the  anterior  vaginal  wall 
will  begin  to  give  way  under  the  greatly  increased  daily  straining  at 
stool,  and  with  it  the  attachment  of  the  bladder  to  the  symphysis,, 
till  cystocele  is  superadded  (Fig.  211). 


OPERATIONS    ON   THE   VAGINA. 


413 


In  addition  to  the  symptoms  already  enumerated  the  patient  will 
now  complain  of  frequency  of  urination,  and  the  usual  results  of  in- 
ability to  empty  the  bladder  will  show  themselves.  There  will  be 
cystitis  and  urethritis,  and  these  in  their  turn  by  causing  increased 
straining  will  aggravate  the  condition. 

Meanwhile  the  uterus  has  become  retro-flexed  from  traction,  and 


"-     -      ^ 

Fig.  211. 
Protocele  and  Cystocele. 


has  begun  to  descend.  Intra-abdominal  pressure  in  this  position  will 
account  for  the  remaining  changes,  which  may  result  in  complete 
prolapsus  uteri. 

When  the  sphincter  ani  has  been  lacerated,  an  additional  train  of 
symptoms  will  be  added,  varying,  according  to  the  extent  of  the  la- 
ceration, from  partial  loss  of  control  over  flatus  to  complete  incon- 
tinence of  wind  and  faeces. 

The  cure  of  these  conditions  is  only  by  operation,  and  as  tlie}^  are 
not  apt  to  exist  without  endometritis  and  are  often  accompanied  by 
laceration   of   the  cervix,  if  the   sui'geon  wishes  really  to  cure  his 


414 


SUEGERY  OF  THE  RECTUM  AND  PELVIS. 


patient  and  relieve  lier  of  her  leucorrhoea  and  backaclie,  as  well  as  of 
her  constipation  and  incontinence  of  faeces,  he  must  be  prepared  to  go 
through  a  considerable  range  of  gynaecology,  which  in  any  case  may 


Fro.  213. 

involve  not  only  repair  of  the  perineum  and  proctocele,  but  also  cu- 
rettage, the  repair  or  amputation  of  the  cervix,  cystocele,  and  replace- 
ment and  fixation  or  removal  of  a  prolapsed  uterus. 

For  the  general  rules  regarding  antisepsis,  preparation  of  the 
patient,  etc.,  for  these  operations,  the  reader  is  referred  to  Chapter  IV. 
In  all,  the  method  of  cleansing  the  vagina  and  external  parts  is  the 
same,  and  consists  in  scrubbing  thoroughly  with  green  soap  and  a 


^^^^^ 

X 

m- 

\ 

• 

*^WV-y 

1 

\ 

^aS 

^ 

..  . 

'^^g^g^ 

"'  -i 

§'• 

*^L 

< 

Fig.  213. 
Stellate  Laceration  of  Cervix. 


long-handled  brush,  after  the  skin  has  been  shaved.    After  scrubbing, 
the  parts  should  be  washed  with  bichloride,  1  to  2,500. 

The  most  convenient  speculum  is  the  one  with  the  loaded  handle 
(Fig.  50),  and  the  most  convenient  needles  are  the  Hagedorn,  held  in 

the  special  holder  made  for  them.     As  many  operations  begun  upon 


OPERATIONS    ON   THE   VAGINA. 


415 


the  vagina  end  in  abdominal  section,  the  patient  should  always  be 
upon  a  table  which  can  be  thrown  into  the  Trendelenberg  position 
without  trouble. 

Operation  for  Lacerated  Cermx. 

Either  the  dorsal  or  lateral  position  may  be  used,  as  the  operator 
prefers.  With  the  dorsal  position  introduce  the  loaded  speculum 
or  perineal  retractor,  and  seize  the  cervix  firmly  with  the  double  ten- 
aculum (Fig.  212). 

Either  with  a  knife  or  strong  sharp-pointed  scissors  first  deepen 
the  laceration   to  be  repaired  by  making  an  incision  through  the 


■k. 

^w^^^ 

^...--^^^'^ 

^^^^ 

^i^*^tm^tf^ 

A 

V^^    -gff 

'''sl^^^^fe 

86li«J^fe& 

§ 

Ml 

*    '"-^ 

^m 

i 

,.« 

^ 

#5 

1 

1' 

^ 

H 

^^ 

'1 

P 

m 

W\ 

i 

^ 

^ 

'^  Vv^"**?** 

^^ 

^ 

Pig.  214. 
Bilateral  Laceration  of  Cervix. 


cicatricial  tissue  in  the  angle  of  the  laceration  down  into  healthy 
uterine  tissue.  Next  denude  thoroughly  both  lips  of  the  old  lacer- 
ation (Fig.  214),  till  all  cicatricial  tissue  is  removed  and  healthy 
muscle  exposed. 

Figs.  215  and  216  show  a  proper  and  improper  denudation  of  the 
lips  of  the  laceration. 


416 


ST7KGERY   OF   THE   RECTUM   AND   PELVIS. 


Fig.  215. 
Denudation  in  Lacerated  Cervix. 


A  strip  of  undenuded  mucosa  must  be  left  on  both  lips  of  the 
cervix  to  form  a  cervical  canal  after  the  suturing  is  completed,  other- 
wise complete  stenosis  will  result  (Fig.  216). 


Fig.  216. 
Incomplete  Denudation  in  Lacerated  Cervix. 


OPERATIOlSrS    ON   THE   VAGINA. 


417 


After  both  lips  of  the  laceration  have  been  vivified,  sutures  are 
introduced  as  follows.  A  small,  full-curved  Hagedorn  needle  should 
be  used  and  silk-worm  gut  is  the  best  material. 

The  first  suture  should  be  passed  at  the  angle  of  the  laceration. 
Enter  the  needle  in  the  vaginal  mucosa  just  above  the  angle,  carry- 
it  through  into  the  cervical  canal,  seize  it  again  and  enter  it  at  the 
corresponding  opposite  point  in   the  canal,  and   bring   out   on  the 


Fig.  317. 
Sutures  in  Laceiated  Cervix. 


vaginal  surface  at  a  point  corresponding  to  the  point  of  entrance. 
About  four  such  sutures  should  be  passed  on  each  side  of  the  cervi- 
cal canal. 

The  ends  of  each  suture  as  passed  should  be  seized  with  a  pair  of 
artery  forceps  to  keep  them  from  becoming  entangled. 

After  all  sutures  have  been  inserted,  each  may  be  tied  or  passed 
through  a  perforated  shot  and  clamped.  In  either  case  the  ends 
should  be  left  at  least  an  inch  long  to  facilitate  removal.     While  the 

27 


418 


SUEGEEY    OF   THE   RECTUM   AND   PELVIS. 


Pig.  218. 
Sutures  in  Lacerated  Cervix. 

sutures  are  being  tied  constant  irrigation  should  be  kept  up  to  re- 
move blood-clots  from  the  incision. 

Pass  a  uterine  sound  to  make  sure  that  the  cervical  canal  has  not 
been  closed  by  sutures,  and  place  a  light  tampon  of  iodoform  gauze 
in  the  vagina.     The  sutures  may,  with'  advantage,  be  left  in  situ  till 


Fig.  219. 
Cervix  after  Repair  of  Laceration. 


OPERATIONS   OX   THE   VAGIXA.  419 

after  the  first  menstrual  period,  as  union  of  tlie  cervical  tissue  is 
always  slow  ;  and  in  cases  associated  with  repair  of  the  perineum 
they  may  be  left  even  longer  to  avoid  pain  and  stretching  of  the 


Fig.  220. 
Forceps  for  Removing  Stitches  from  the  Cervix. 

parts  in  their  removal.  They  are  then  best  removed  in  the  lateral 
position  with  a  Sims  speculum  and  long  forceps  (Fig.  220j.  and 
curved  sharp-pointed  scissors  (Fig.  221). 


Fig.  221. 
Scissors  for  Removing  Stitches  from  the  Cervix. 

The  iodoform  gauze  should  be  removed  from  the  uterus  in  fort}^- 
eight  hours,  and  w^arm  antiseptic  douches  should  be  used  daily  there- 
after. 

The  patient  should  be  confined  to  the  bed  for  ten  days,  and  to  the 
house  a  week  longer. 

Amputation  of  tJie  Ceriilx. 

Removal  of  a  portion  or  the  entire  cervix  may  be  indicated  in  : 

Carcinoma. 

Prolapsus  uteri. 

Infra-vaginal  elongation. 

Supra-vaginal  elongation. 

Chronic  metritis. 

Elongation  due  to  laceration. 

General  cystic  degeneration. 

The  operation  may  be  done  below  the  vaginal  junction,  as  in  com- 
mencing carcinoma  and  the  usual  forms  of  elongation  ;  or,  amputa- 
tion above  the  vaginal  junction  may  be  necessary,  as  in  supra- 
vaginal elongation  and  more  advanced  malignant  disease. 


420 


SURGEEY    or   THE   RECTUM   AXD   PELVIS. 


Fig.  222. 

Hypertrophy  of  Supra-Vaginal  Portion  of  the  Cervix. 


High  Amjndcition  of  the  Cermx. 

This  is  performed  in  its  first  steps  as  a  vaginal  liysterectomy  with 
ligatures  would  be. 

The  instruments  necessary  are  : 

Knife. 

Yolsellum. 

Scissors. 

Artery  forceps. 

Strong  catgut. 

Curved  Hagedorn  needles. 

Needle-holder. 

"Uterine  sound. 

Speculum. 

Cleveland  lio;ature  carrier. 


OPERATIONS   ON   THE   VAGINA. 


421 


Fig.  223. 


Ovarian,  Uterine  and  Vaginal  Arteries. 

a,        Ovarian  artery. 

a'  6',  Branches  to  tubes. 

6,        Branch  to  round  ligament. 

c,        Uterine  artery. 

c',       Branches  to  ovary. 

g,        Vaginal  artery. 

A,       Azygos  vaginae. 


422  SURGERY    OF   THE   RECTUM   AND   PELVIS. 

Having  introduced  the  speculum  and  pulled  down  the  cervix,  an  in- 
cision is  made  around  the  cervix,  taking  care  to  avoid  the  bladder,  and 
the  vaginal  mucosa  is  stripped  up  by  blunt  and  sharp  dissection.  The 
uterine  arteries  are  then  tied  on  each  side  (Fig.  222)  as  in  hysterec- 
tomy, using  either  the  Cleveland  ligature  carrier  or  a  curved  needle 
and  heavy  catgut.  The  dissection  is  next  carried  upward  along  the 
cervix  on  each  side  till  the  portion  contained  in  the  ligatures  is  sep- 
arated from  the  uterus.  If  the  uterine  arteries  have  been  secured 
there  will  be  but  little  hemorrhage. 

The  anterior  portion  of  the  cervix  is  then  cut  across  transversely 
down  to  the  canal.  Should  this  cause  free  hemorrhage  the  best 
method  of  securing  the  bleeding  points  is  not  with  artery  forceps, 
but  by  carrying  a  curved  needle,  armed  with  fine  catgut,  under  them, 
and  tying  them  with  the  tissue  in  which  they  lie.  After  stopping 
the  bleeding  of  the  anterior  portion  in  this  way  the  posterior  is  cut 
across. 

The  suturing  of  the  divided  vagina  to  the  uterine  mucosa  is  done 
with  catgut,  the  ligatures  around  the  uterine  arteries  having  been  cut 
short. 

Should  the  peritoneum  have  been  opened  posteriorly,  it  must  be 
sutured  separately  with  fine  catgut.  The  suture  which  unites  the 
vagina  to  the  uterine  mucosa  passes  first  through  the  cut  edge  of  the 
vagina,  next  through  the  stump  of  the  cervix,  and  is  brought  out  in 
the  cervical  canal  and  tied. 

Should  it  be  found  impossible  to  reach  satisfactorily  above  the 
disease  in  carcinoma  the  attempt  at  high  amputation  may  be 
abandoned  and  vaginal  hysterectomy  substituted. 


Wedge-shaped  Amputation  of  tTie  Cermx. 

The  operation  usually  performed  in  cases  of  infra-vaginal  elonga- 
tion is  the  removal  of  a  wedge-shaped  piece  from  each  lip  and  the 
formation  of  double  fiaps. 

The  cervix  is  brought  down  into  view,  as  in  the  former  operation, 
and  with  a  strong  pair  of  straight  scissors,  one  blade  of  which  is 
passed  into  the  canal,  both  sides  are  split  open  as  far  down  as  the 


OPEEATIONS    ON    THE   VAGINA. 


423 


Fig.  224. 
Flaps  Formed  in  Amputation  of  Cervix. 


Fig.  225. 
Appearance  of  Stump  after  Amputation  of  Cervix. 


424 


SURGERY    OF    THE    RECTUM    AXD    PELVIS. 


junction  with  tlie  vagina.    A  wedge  is  tlien  removed  from  each  lip  of 
the  shape  shown  in  Fig.  224. 

Tlie  resulting  appearance  is  shown  in  Fig.  225. 

Sutures  of  silk-worm  or  chromicized  gut  may  be  used,  and  the 


Fig.  226. 
Sutures  in  Amputation  of  Cervix. 


first  two  on  each  flap  are  so  introduced  as  to  draw  open  the  cervical 
canal.  The  others  pass  through  all  four  flaps,  as  shown  in  Fig.  226. 
The  result  being  shown  in  Fig.  227. 

The  stitches  niay  be  tied  after  all  have  been  inserted,  or  each  one 
may  be  tied  as  it  is  inserted.  If  there  is  free  bleeding  it  is  best  con- 
trolled by  immediately  inserting  a  stitch  through  that  part  of  the 
stump  and  tying  it.  In  this  way  no  separate  ligation  of  vessels  will 
be  necessary. 


OPERATIONS    OX    THE   YAGIXA. 


425 


A  strip  of  gauze  sliould  be  inserted  into  the  uterus,  the  vagina 
lightly  tamponed  with  iodoform  gauze,  and  the  case  treated  as  in  the 
operation  for  laceration. 

Operation  for  Lacerated  Perineum. 

The  operative  procedures  vary  according  as  the  laceration  is  com- 
plete or  incomplete,  old  or  recent. 

All  lacerations  should  be  repaired  within  twenty-four  hours  of 
their  occurrence  if  the  patient  is  in  condition  to  bear  the  oi^eration, 
as  under  these  circumstances  no  denudation  is  necessary,  and  the 
suturing  can  easily  be  done  under  cocaine.     None  but  the  slighter 


Fig.  227. 
Cervix  aftar  Amputation. 


tears  extending  only  through  the  raucous  membrane  of  the  vagina 
should  be  left  to  close  by  granulation,  for  though  perfect  union  may 
occur,  it  is  rare.  The  operation  for  recent  rupture,  either  partial  or 
complete,  will  readily  be  understood  after  description  of  the  tech- 
nique in  old  cases. 


426 


SURGERY    OF   THE   RECTUM   AND   PELVIS. 


Old  Incomplete  Laceration. 

The  extent  of  the  denudation  will  vary  according  to  the  condition 
of  the  parts.  Should  there  be  no  proctocele  or  cystocele,  the  denu- 
dation need  cover  only  the  part  torn  and  united  by  cicatrix,  and 
need  not  extend  into  the  vagina  as  shown  in  Fig.  228. 


Fig.  338. 
Incisions  for  Repair  of  Lacerated  Perineum. 


On  the  other  hand,  should  there  be  a  proctocele  the  denudation 
must  be  carried  as  far  as  its  highest  point.  The  proctocele  is  in 
reality  a  hernia  of  the  anterior  wall  of  the  rectum  into  the  vagina, 
caused  by  the  laceration  and  separation  of  the  fibres  of  the  levator 
ani  and  the  pelvic  fascia,  and  for  its  cure  these  separated  fibres  must 
be  united  by  sutures  for  their  entire  extent. 

To  do  this,  and  to  close  the  vaginal  entrance,  a  triangular  denuda- 
tion is  necessary,  with  its  base  at  the  skin  of  the  perineum  and  its 
apex  at  the  highest  point  of  the  proctocele  within  the  vagina  (Fig. 
230). 

The  three  angles  of  the  triangle  should  first  be  marked  by  snip- 
ping out  small  pieces  of  the  mucous  membrane.     One  of  the  lower 


OPERATIONS    ON    THE    VAGINA. 


427 


angles  is  on  each  of  the  labia,  and  the  base  of  the  triangle  corre- 
sponds to  the  fourchette,  and  should  be,  in  moderate  cases,  about  two 
inches  long.  The  apex  of  the  triangle  should  be  marked  upon  the 
uppermost  point  of  the  proctocele,  or  even  a  little  above  this,  nearer 


';■!'■ 

^ 

^& 

/\        '  ' 

^^^ 

^;; 

% 

1 

7/\ 

\ 

^^?» 

O 

'&'  ■ 

% '  ^ 

n^'^' 

'1;;./               .'^^>^? 

'•■£   ■'■:    ■': 

.m\,...u  ,;.:M 

Fig.  229. 
Denudation  in  Slight  Laceration. 


the  cervix  ;  and  these  three  points  should  be  connected  by  lines  cut 
w^ith  a  knife  through  the  mucous  membrane  for  guides  in  denuding. 

The  outlining  incisions  in  the  form  of  a  triangle  should  extend 
completely  through  the  mucous  membrane  at  all  points  to  enable  the 
operator  to  remove  the  contained  portion  of  mucous  membrane  easily 
and  rapidly. 

The  denudation  may  be  made  either  v^^ith  scissors  in  successive 


428 


SURGERY  OF  THE  RECTUM  AND  PELVIS. 


strips,  or  with  the  knife  in  one  piece,  and  in  either  case  the  whole 
thickness  of  the  mucous  membrane  should  be  removed. 

If  the  knife  is  used  the  apex  of  the  triangle  is  seized  with  forceps 


Fig.  230. 
Hegar's  Colpo-Perineorrhaphy. 

and  dissected  loose  till  a  firm  hold  upon  it  can  be  secured  with  the 
fingers,  when  the  whole  piece  can  be  rapidly  stripped  down  with  the 
aid  of  a  few  strokes  of  the  knife. 

With  scissors  the  denudation  is  begun  at  the  base  and  carried 


%■  o  ^ 


Fig.  231. 
Angular  Scissors  for  Denudation  of  Perineum. 


from  one  side  to  the  other  and  back  again  (Fig.  229)  in  successive 
strips,  each  of  which  is  shorter  than  the  preceding.  To  do  this  nicely 
requires  considerable  practice,  and  the  scissors  shown  in  Fig.  231. 


OPERATIONS   ON   THE   VAGINA. 


429 


;/  / 


0'^ 


Fig.  23:2. 
Denudation  in  Perineorrhaphy. 


430  SUEGEEY    OF   THE    IlECTUM   AND    PELVIS. 

Another  way  of  denuding  is  to  cut  a  hole  through  the  thick- 
ness of  the  mucous  membrane  at  the  middle  of  the  base  of  the  tri- 
angle, insert  the  blades  of  a  pair  of  blunt -pointed  scissors  under  the 
mucous  membrane,  and  push  them  upward  till  the  apex  is  reached. 
By  opening  and  closing  them,  and  working  them  backward  and  for- 
ward in  blunt  dissection,  the  whole  triangle  may  easily  be  stripped 
up  from  the  submucous  connective  tissue  and  then  cut  away. 

The  objection  to  this  method  is  that  to  accomplish  it  safely  with- 
out perforating  the  rectum  two  fingers  need  to  be  inserted  into  that 
canal,  and  these  fingers  at  some  subsequent  step  in  the  suturing  are 
more  than  likely  to  come  in  contact  either  with  the  wound  or  the 
sutures  (Fig.  232)  without  being  resterllized. 

When  by  any  of  these  methods  the  denudation  has  been  com- 
pleted, the  edges  of  the  wound  made  straight  and  even,  and  all  bits 
of  mucous  membrane  which  may  have  escaped  in  the  denudation 
carefully  removed,  the  raw  surface  should  be  irrigated,  marked 
bleeding  checked  by  hot  water,  torsion,  or  even  a  fine  ligature,  and 
the  suturing  begun. 

This  should  be  continuous,  with  medium  catgut,  and  begin  at  the 
apex.  The  suture  should  not  pass  across  the  raw  surface  from  one 
edge  to  the  other,  but  be  buried  in  the  submucous  tissue  under  the 
denuded  surface. 

If  the  denudation  has  been  large  and  wide  in  the  vagina  it  will  be 
best  to  draw  its  sides  together  by  a  row  of  buried  sutures  before 
attempting  to  close  the  mucous  membrane  over  it,  otherwise  the 
tension  on  the  cut  edges  of  the  membrane  is  liable  to  cause  the 
sutures  to  cut  out,  and  failure  to  get  primary  union  will  result. 

When  by  a  continuous  suture  the  proctocele  has  been  closed,  the 
suture  may  be  tied  and  cut,  and  two  or  three  stronger  sutures,  or 
sutures  of  silk-worm  gut,  may  be  used  in  the  perineum  to  close  that 
portion  of  the  denudation  and  the  vaginal  outlet  (Fig.  230). 

A  simple  and  efiicient  suture  is  that  of  Cleveland,  show^n  in  Fig. 
233.  It  can  be  introduced  while  the  fingers  are  stiU  in  the  rectum  if 
denudation  has  l>een  done  by  the  method  shown  in  Fig.  232  and 
finished  very  rapidly.  A  strong  piece  of  catgut  should  be  used,  and 
a  long  straight  needle,  which  is  entered  at  1,  brought  out  at  2,  entered 
again  at  2,  and  brought  out  at  3,  carried  over  to  4  and  passed  to  5, 


OPERATIONS   ON   THE  VAGINA. 


431 


entered  again  at  5  and  brought  out  at  6,  and  tied  after  it  has  been 
tightened  sufficiently  to  draw  the  denuded  surfaces  together. 

The  best  after-dressing  is  a  pad  of  iodoform  gauze  over  the  sutures, 
and  another  of  plain  gauze  over  the  vulva,  held  in  place  by  a  bandage. 
Care  should  be  exercised  to  keep  the  vulva  clean  after  urination. 


Fig.  233. 
Cleveland  Suture. 


The  catheter  should  be  used  for  the  first  three  days,  and  a  douche 
of  bichloride  employed  after  its  use  and  after  subsequent  voluntary 
micturition.  The  bowels  should  not  be  confined  more  than  forty- 
eight  hours  and  a  saline  should  then  be  given.  When  the  patient 
feels  that  the  saline  is  about  to  have  its  effect  an  enema  of  simple 


432 


SUKGERY    OF   THE   EECTOI    A:S'D    PELVIS. 


warm  water  should  be  administered  to  give  an  easy  passage  without 
straining. 

The  patient  should  be  confined  to  the  bed  for  two  weeks,  and  in 
the  house  at  least  a  week  longer. 

If  by  any  fault  failure  to  get  union  by  first  intention  is  encoun- 
tered, a  second  operation  may  be  necessary,  though  in  some  of  the 
.slighter  cases,  unattended  by  prolapsus  of  the  uterus,  a  good  result 
may  follow  union  by  granulation. 

Old  Laceration  through  the  Sphincter. 

When  the  rupture  has  extended  through  the  sphincter,  the  den- 
udation is   the   same,  except   that  it  must   be   carried  far   enough 


f¥/^ 


'i    >  /c^ 


#7»^V'-' 


■;yM: 


m 


Fig.  234. 
Denudation  in  Laceration  through  the  Sphincter. 


downward  to  expose  the  separated  ends  of  the  muscle,  which  can 
generally  be  made  out  with  a  little  care  (Fig.  234). 

The  sutures  may  be  applied  as  in  the  last  case,  except  that  the 


OPERATIONS    ON    THE   VAGINA. 


433 


Fig.  235. 
Sutures  in  Laceration  through  the  Sphincters. 

lowest  ones  must  be  so  inserted  as  to  approximate  the  ends  of  the 
muscle.  To  do  this  the  needle  must  be  inserted  and  brought  out  on 
the  cutaneous  surface  below,  and  not  above  the  divided  ends,  as 
shown  in  Fig.  285. 

Another  method  is  to  reduce  a  complete  laceration  through  the 


s»l 


/    \ 


Fig.  330. 
Rectal  Sutures  in  Complete  Laceration. 


434 


SURGERY  OF  THE  RECTUM  AND  PELVIS. 


sphincters  and  septum  to  a  partial  one,  involving  only  the  vaginal 
mucosa  and  the  superficial  perineum,  by  introducing  first  a  row  of 
rectal  sutures,  as  shown  in  Fig.  236,  and  second  a  row  of  vaginal  ones, 
as  shown  in  Fig.  237. 

The  sutures  may  be  interrupted,  as  shown  in  the  cuts,  or  continu- 
ous, as  the  operator  prefers,  and  should  be  of  medium  catgut. 


Fig.  237. 
Vaginal  Sutures  in  Complete  Laceration. 

The  dressings  are  the  same  as  in  partial  laceration,  and  the 
bowels  should  be  moved  by  laxatives  and  enema,  not  later  than  the 
third  day.  The  diet  for  the  first  two  or  three  days,  however,  should 
be  of  beef-tea  and  animal  food,  exclusive  of  milk,  in  order  that  the 
first  passages  may  be  as  small  as  possible. 

In  lacerations  through  the  recto-vaginal  septum,  the  denudation 
should  always  be  carried  far  enough  above  the  highest  point  of  the 
laceration  to  secure  union  without  the  formation  of  a  recto-vaginal 
fistula. 


OPERATIONS   ON   THE   VAGINA. 


435 


Laceration  of  the  Sexdum  without  Laceration  of  the  Sphincters. 

In  cases  of  laceration  of  the  septum  without  laceration  of  the 
sphincter,  after  the  laceration  has  been  closed  by  a  flap-splitting 
operation,  such  as  is  described  under  recto-vaginal  fistula,  or  by  a 
continuous  suture  from  the  rectal  or  vaginal  surfaces,  the  sphincter 
should  be  completely  paralyzed  by  stretching,  and  the  bowels  should 
be  confined  for  three  days  to  allow  of  union.  The  diet  should  be 
exclusively  of  meat  and  beef- tea. 

Grreat  care  should  be  used  to  secure  soft  movements  from  the 


Fig.  338. 
Emmet's  Operation  for  Cystocele. 


first ;  and  this  is  best  accomplished  by  a  restricted  diet  and  by  fre- 
quent small  doses  of  some  saline  cathartic  after  the  third  da}^  to  be 
followed  by  an  enema  when  the  bowels  are  about  to  act.  Milk 
should  be  avoided  during  the  first  week  on  account  of  its  tendency 
to  produce  large  solid  motions. 


436 


SURGERY   OF   THE   RECTUM   AND    PELVIS. 


Fig.  289. 
Stoltz's  Operation  for  Cystocele  Combined  with  Perineorrhaphy  by  Cleveland  Suture. 


i''iG.  240. 
Combined  Stoltz  and  Hegar  Operation. 


OPERATIONS    ON   THE    VAGIXA. 


437 


Operation  for  Cystocele. 

Emmet's  operation  is  as  shown  in  Fig.  238.  The  denudation  is 
now  nsually  closed  with  a  continnoas  catgut  suture  from  behind 
forward.     The  catheter  should  be  used  frequently   until  complete 


Fig.  241. 
Complete  Prolapse  with  Ulceration  (Personal). 

■union  has  had  time  to  take  place.  The  combined  Stoltz's  operation 
for  cystocele  with  colpo-perineorrhaphy  are  shown  in  Figs.  239  and 
240. 

Prolapse  of  tlie   Uterus. 

The  operative  treatment  of  prolapse  of  the  uterus  must  depend  upon 
its  degree.  In  the  mild  cases  in  which  the  cervix  is  still  within  the 
vagina  the  plastic  operations  already  described  may  be  sufficient  to 


438 


SURGERY    OF    THE    EECTU^I    AXD    PELVIS. 


retain  it  at  least  from  further  descent.  Tliey  should  be  performed  in 
the  following  order.  The  uterus  should  be  first  curetted  and  then,  if 
the  cervix  is  enlarged,  as  it  usually  will  be,  it  should  be  amputated. 
Plastic  operations  upon  the  vagina  and  perineum  are  next  in  order, 
and  of  these  several  may  be  performed  on  the  same  patient.  For  ex- 
ample, a  lateral  colporrhaphy  may  be  done  on  each  side,  then  an  an- 
teiior,  and  finally  colpo-perineorrhaphy.  Or  Le  Fort's  method  of 
closing  the  vagina  by  uniting  a  large  denuded  surface  on  the  anterior 
wall  to  one  on  the  posterior  may  be  done  (Figs.  242,  243).     Or  the 


Fig.  242. 


Le  Fort's  Operation  for  Closure  of  the  Vagina. 


A.  Anterior  Denudation. 

B.  Posterior  Denudation. 
UR.   Urethra. 


vagina  may  be  greatly  contracted  by  passing  circular  sutures  around 
it  at  intervals  of  an  inch  under  the  mucous  membrane,  and  drawing 
them  so  tightly  as  to  leave  only  a  small  canal  for  the  escape  of  se- 
cretions. 


OPERATIONS    OX   THE   VAGINA. 


439 


Such  an  operation  is  only  applicable  to  cases  in  women  wlio  have 
passed  the  menopause,  and  in  whom  there  is  no  expectation  of  future 
sexual  intercourse. 

In  the  more  severe  cases,  in  addition  to  the  plastic  work,  either  an 
Alexanders  operation  of  shoitening  the  round  ligaments  or  a  ventral 


Denuded  surfaces  A  and  B  brought  into  Apposition. 
C  C'.   Suture  introduced  readj-  to  tie. 

fixation  may  be  added.     If  the  former  be  employed  it  should  be  done 
thoroughl}^  and  radically,  as  described  under  that  head. 

In  the  still  more  advanced  cases  of  complete  prolapsus  vaginal 
hysterectomy  may  be  the  only  cure.  In  women  past  the  meno^Dause 
it  may  be  only  a  waste  of  time  to  tr}^  any  other  milder  procedure. 
In  younger  women,  who  are  still  liable  to  have  children,  the  milder 
operations  should  first  be  tried,  and  Alexander's  operation  should 
have  preference  over  abdominal  fixation  on  account  of  the  fact  that 
it  leaves  the  organ  in  a  much  safer  position  for  future  pregnancy, 
although  it  is  not  as  ceitain  in  its  results  in  this  form  of  disease. 


440  SURGERY    OF   THE    RECTUM    AND    PELVIS. 

Exploration  of  the  Pelvis  through  the  Vagina. 

The  vagina  may  be  opened  either  in  front  or  behind  the  uterus  for 
exploration  and  for  such  operative  procedures  as  exploration  may 
prove  to  be  necessary. 

Anterior  Colpotomy. 

A  transverse  incision  is  made  across  the  cervix  low  enough  down 
to  escape  the  vesical  fold,  the  cervix  being  held  well  down  with  the 
volsellum.  This  incision  may  be  made  either  with  knife  or  cautery 
iron.  The  latter  will  sometimes  save  hemorrhage,  but  any  bleeding 
caused  by  the  former  is  easily  controlled  by  whipping  over  the  cut 
edge  of  the  vagina  with  a  running  catgut  suture. 

AVith  the  fingers  or  handle  of  the  scalpel  the  incision  is  next 
deepened  till  the  bladder  is  separated  from  the  uterus  and  the  per- 
itoneum laid  open.  The  peritoneum  is  sometimes  quite  heavy  and 
strong,  and  may  require  knife  or  scissors  to  open  it  nicely,  with- 
out too  much  tearing. 

When  the  peritoneum  is  opened  one  or  two  fingers  are  passed 
into  the  opening  and  the  anterior  surface  of  the  uterus,  with  the  broad 
ligaments,  tubes,  and  ovaries,  palpated.  Any  adhesions  may  be 
broken  up,  and  where  the  disease  is  not  too  extensive  and  has  not 
matted  the  organs  too  firmly  together,  the  uterus  may  first  be  rotated 
so  that  its  fundus  shall  appear  in  the  vagina  through  the  incision,  and 
the  tubes  and  ovaries,  first  on  one  side  and  then  on  the  other,  may  be 
brought  out  after  it. 

In  this  position  minor  work  on  the  ovaries,  such  as  puncturing  of 
cysts,  may  easily  be  done,  or  an  ovary  may  be  tied  off  and  removed. 
The  tubes  may  be  treate.d  in  the  same  way.  Should  there  be  hydro- 
salpinx or  pyosalpinx  the  tube  should  be  aspirated  as  it  is  held  in 
the  incision  before  attempting  to  bring  it  out,  and  a  very  large  ovary 
should  be  treated  in  the  same  way. 

Posterior  Colpotomy. 

Here  the  incision  may  be  transverse  or  vertical,  according  to  the 
taste  of  the  operator.  The  vertical  will  give  less  hemorrhage  ;  the 
transverse  is  thought  by  many  to  give  easier  access  to  the  parts. 


OPERATIONS   ON   THE   VAGINA.  441 

Through  this  incision  all  the  work  done  by  the  anterior  route  can 
be  clone  as  well,  and  the  choice  of  the  two  operations  is  in  great 
measure  a  matter  of  practice  and  familiarity  with  different  operators. 
The  posterior  operation  is,  however,  to  be  chosen  in  all  cases  of  pelvic 
abscess  which  the  surgeon  desires  to  evacuate  through  the  vagina. 

The  ease  with  which  an  exploratory  colpotomy,  either  anterior  or 
posterior,  may  be  turned  into  a  complete  hysierectomy,  should  the 
adnexa  be  found  to  demand  it,  is  apparent.  In  such  a  case  it  is  pos- 
sible to  remove  uterus,  both  tubes  and  both  ovaries  in  one  piece,  but 
it  will  generally  be  better  and  easier  to  finish  first  with  the  uterus, 
clamping  the  tubes  at  the  cornua  for  a  guide  as  they  are  divided,  and 
then  returning  to  them  and  enucleating  each  with  the  correspond- 
ing ovary  in  turn. 

When  pus  is  found,  unless  the  organ  containing  it  can  be  re- 
moved before  the  sac  is  ruptured,  the  vaginal  incision  should  be  left 
open,  with  a  gauze  drain  inserted.  In  non-septic  cases  the  wound  in 
the  vagina  and  the  one  in  the  peritoneum  may  both  be  closed  with 
fine  catgut. 

•  Vaginal    Verus  Abdominal  Section. 

In  deciding  whether  to  operate  in  any  particular  case  by  the  vagi- 
nal or  abdominal  route,  the  following  indications  laid  down  by  Polk 
are  of  interest  as  showing  his  personal  preference,  based  upon  the  re- 
sults of  his  own  experience  : 

^''Vaginal  Section.  Abdominal  Section. 

1.  A  shallow  and  wide  pelvis  in  1.  A  narrow   and   deep  pelvis, 
a  thin  woman.  especially  if  deformed. 

2.  Explorations  of  the  pelvis.  2.  Explorations  above  the  true 

pelvis. 
.   3.  Visceral   adhesions    in    true         3.  Visceral  adhesions   in   false 
pelvis.  pelvis  or  above. 

4.  Displaced  and  adherent  ute-         4.  Large   ovarian   cysts,    espe- 
rus.  cially   multilocular,   with  colloid 

contents. 

5.  Smaller    ovarian    cysts,    es-         5.  Large  fibroids,  especially  the 
pecially  the  intraligamentous  and     firm  and  hard. 

parovarian. 


442 


SURGERY    OF   THE    RECTUM   AND    PELVIS. 


Vaginal  Section. 

6.  Smaller  fibroids,  especially 
the  soft. 

7.  Extra-uterine  pregnancy,  up 
to  seventh  month,  and  after  death 
of  foetus. 

8.  Pelvic  hsematocele. 

9.  Puerperal  hysterectomy. 


Abdominal  Section. 

6.  Extra-uterine  pregnancy  at 
time  of  rupture  and  at  term. 

7.  Extra  -  uterine  pregnancy, 
with  tumor  wholly  above  brim  of 
pelvis,  and  not  in  relation  with 
uterus. 

8.  Pelvic  abscess  pointing  up- 
ward. 

9.  Conservative  operations  un- 
der conditions  unfavorable  to  vag- 
inal section,  such  as  a  narrow  and 
deep,  or  a  deformed  pelvis,  that 
is  contracted. 

10.  Acute  inflammation  of  ap- 
pendages, with  peritonitis  involv- 
ing cul-de-sac. 

11.  Inflammatory  destructive 
diseases  of  the  appendages,  in 
eluding  tubercuUir  disease. 

12.  Pelvic  abscess  pointing 
downward. 

13.  Conservative  operations  on 
appendages  that  lie  in  true  pelvis." 

He  believes  that  seventy -five  per  cent,  of  all  cases  are  best  treated 
by  the  vaginal  route. 

Urethrocele. 

The  differential  diagnosis  between  cystocele  and  urethrocele  can 
generally  only  be  made  by  passing  a  bent  probe  into  the  tumor 
from  the  meatus.  In  urethrocele  the  posterior  wall  of  the  urethra 
will  be  found  much  longer  than  the  anterior,  and  the  probe  will  drop 
into  a  pouch  just  within  the  meatus,  and  from  this  can  be  passed 
into  the  bladder.  The  w^all  of  the  urethrocele  may  be  either  thicker 
or  thinner  than  natural.  The  tumor  will  not  generally  be  larger  than 
the  end  of  the  thumb. 


OPERATIONS   ON   THE   YAGlNA. 


443 


Tlie  symptoms  of  this  affection  do  not  in  any  way  distinguish  it 
from  a  general  cystitis,  being  frequent  micturition,  with  pain  and 
spasm,  incontinence  of  urine,  and  pus,  either  mixed  with  the  urine 
or  in  okl  cases  escaping  by  itself  from  the  meatus. 

The  cause  of  the  urethritis  is  mechanical,  and  local  applications 


Fig.  244. 

Emmet's  Buttonhole  Operation  for  Cystocele. 


to  the  distended  pouch  will  generally  give  but  little  relief  as  long  as 
the  decomposing  urine  is  allowed  to  remain  in  the  sac. 

The  proper  treatment  consists  in  draining  the  sac  through  the 
vagina  by  establishing  a  permanent  urethro-vaginal  fistula,  as  shown 
in  Fio;.  244. 


444  SURGERY    OF   THE    RECTUM    AND   PELVIS. 

After  such  an  opening  lias  been  established  the  treatment  of  the 
urethritis  becomes  an  easy  matter. 

The  operation  is  in  itself  simple,  the  point  to  be  guarded  against 
being  injury  to  the  neck  of  the  bladder  and  meatus  by  too  long  an 
incision. 

The  patient  maj"  be  in  either  the  dorsal  or  Sims  position,  prefer- 
ably the  former,  and  the  incision  into  the  sac  slioukl  be  made  upon 
the  end  of  a  uterine  sound,  firmly  held  by  an  assistant.  As  soon  as 
the  sound  is  reached  it  should  be  pushed  through  into  the  vagina 
and  be  retained  in  that  position  until  the  mucosa  has  been  stitched. 
The  incision  into  the  sac  should  be  about  half  an  inch  in  length. 

The  mucous  membrane  of  the  vagina  is  stitched  to  that  of  the 
urethrocele  with  fine  black  silk. 

By  this  operation  not  onlj^  is  the  patient  greatl}^  relieved  of  all 
the  worst  symptoms  at  once,  for  there  is  no  incontinence  of  urine,  but 
the  way  is  opened  to  the  direct  treatment  of  the  diseased  mucous 
membrane. 

After  a  time  the  urethra  will  regain  its  normal  condition,  and  the 
fistula  may  be  closed  as  any  vesico-vaginal  fistula  would  be. 

Caruncle  of  the   Urethra. 

Smaller  caruncles  at  the  meatus  urinarius  may  be  cured  by  appli- 
cations of  nitric  acid,  but  they  are  very  apt  to  grow  again,  and  the 
better  plan  is  to  resect  them  and  suture  the  healthy  mucosa  over  the 
incision.  In  cases  of  larger  growths,  involving  a  considerable  portion 
of  the  meatus,  this  will  be  the  onh^  satisfactory  treatment. 

Prolapse  of  the   Urethra. 

Prolapse  of  the  urethra  is  very  similar  to  prolapse  of  the  rectum, 
and  all  of  the  methods  of  treating  the  latter  have  been  applied  to  the 
former.  Cauterization  in  stripes  may  be  efficient;  amputation  and 
suture  after  pulling  the  mucosa  as  far  down  as  possible  seem  to  be 
more  radical. 

Emmet  has  modified  the  buttonhole  operation  to  apply  to  these 
cases,  and  through  the  incision  shown  in  the  figure,  draws  out  and 
amputates  the  prolapsing  mucosa.     The  incision  may  be  closed  at 


OPERATIONS    ON   THE   VAGINA.  445 

once  or  may  be  left  open  for  a  time  for  treatment  of   the  mucous 
membrane  should  it  be  indicated. 

In  performing  this  operation  a  sound  should  previously  be  passed 
into  the  bladder,  and  allowed  to  remain  till  the  operation  is  com- 
pleted.    This  smooths  out  the  mucosa  and  reduces  the  prolapse. 

Cystotomy  in   Women. 

Cystotomy  in  the  female  may  be  indicated  for  many  of  the  same 
conditions  as  in  men,  viz.  : 

Cystitis. 

Calculus. 

JS'eoplasms. 

Foreio:n  bodies. 

Wounds. 

Usuall}^  an  operation  through  the  vagina  will  be  all  that  is  re- 
quired, but  occasionally,  as  in  the  case  of  a  very  large  calculus  or  a 
rent  in  the  bladder  wall,  the  supra-pubic  incision  may  be  indicated 
either  alone  or  in  connection  with  the  vaginal. 

The  supra-pubic  operation  in  women  is  the  same  as  in  men,  and 
to  that  the  reader  is  referred  for  the  description. 

The  operation  through  the  vagina  is  as  follows  : 

With  the  patient  in  the  dorsal  position  and  the  feet  in  upright 
supports,  an  ordinary  uterine  probe  or  VanBuren's  sound  of  medium 
size  is  passed  into  the  bladder  and  made  to  press  with  its  tip  upon 
the  bladder-wall  in  the  median  line,  and  midway  between  the  cervix 
and  the  neck  of  the  bladder.  This  serves  for  a  guide  for  the  incision, 
which  should  at  first  be  only  large  enough  to  allow  the  escape  of  the 
tip  of  the  sound  into  the  vagina. 

After  the  edges  of  this  incision  have  been  secured  with  fine  forceps, 
so  that  the  relation  between  the  vesical  mucous  membrane  and  that 
of  the  vagina  cannot  be  changed,  the  incision  may  be  enlarged  to 
half  an  inch  with  scissors. 

The  points  to  be  guarded  against  are  : 

Sliding  of  the  mucous  membrane  of  the  bladder  away  from  the 
primary  incision  so  that  the  openings  into  the  vagina  and  into  the 
bladder  are  not  in  apposition. 


446  SURGERY   OF   THE   RECTUM   AND    PELVIS. 

Injury  to  the  ureters,  which  is  best  avoided  by  making  the  in- 
cision exactly  in  the  median  line. 

The  after-treatment  must  depend  entirely  upon  the  conditions 
found  when  the  bladder  is  opened. 

If  these  be  such  as  to  justify  an  immediate  closure,  as  in  cases  of 
stone  or  foreign  bodies,  with  very  little  attendant  cystitis,  the  incision 
may  at  once  be  sutured  with  fine  silk,  and  a  catheter  left  in  till  heal- 
ing is  complete. 

On  the  other  hand,  should  permanent  drainage  be  necessary,  the 
incision  is  kept  open  by  suturing  the  mucous  membrane  of  the  blad- 
der to  that  of  the  vagina,  as  in  the  buttonhole  operation  for  cysto- 
cele. 

Should  it  be  intended  by  the  operator  to  establish  drainage  for  a 
considerable  time  some  arrangement  should  be  made  at  the  time  of 
the  operation  for  the  future  comfort  of  the  patient.  This  is  best 
done  by  inserting  into  the  bladder  a  bent  glass  tube,  with  a  flange  at 
the  end,  and  tightly  suturing  the  edges  of  the  incision  around  it.  A 
rubber  tube  attached  to  this  and  carried  to  a  rubber  bag  worn  upon 
the  thigh,  from  which  the  ui'ine  may  be  drawn  off  at  will,  provides 
all  that  is  possible  in  the  way  of  comfort. 


CHAPTER    XXIII. 

FIXATION   OF  THE  UTEEUS   AND  SHORTENING   THE   ROUND  LIGA- 
MENTS. 

Vaginal  Fixation. 

This  is  in  reality  an  anterior  colpotomy,  witli  snture  of  the  fun- 
dus of  the  uterus  to  the  anterior  wall  of  the  vagina  at  the  point 
of  incision. 

The  incision  is  made  vertical  instead  of  around  the  neck  of  the 
uterus,  as  is  usual  in  anterior  colpotomy,  and  the  peritoneum  is 
opened.  The  fundus  of  the  uterus  is  next  seized  with  a  volsellum 
and  brought  to  the  incision.  Two  sutures  are  passed  through  its 
substance,  as  in  a  ventral  fixation,  and  the  ends  brought  out  on  each 
side  of  the  incision.  After  closing  the  vaginal  wound,  the  fixation 
sutures  are  tied. 

The  operation  is  not  regarded  as  justifiable  in  women  liable  to 
become  pregnant,  on  account  of  the  distortion  it  causes  in  the  posi- 
tion of  the  uterus. 

Ventral  Fixation  of  the   Uterus. 

This  is  the  operation  of  choice  in  cases  of  prolapsus  in  which 
plastic  work  upon  the  uterus  and  vagina  fail  to  effect  a  cure. 

When  done  for  retro-displacements,  the  operation  presupposes 
the  freeing  of  the  organ  from  all  adhesions. 

A  two-inch  incision,  as  close  to  the  symphysis  as  possible  without 
wounding  the  bladder,  is  generally  sufficient,  and  only  two  fingers 
need  be  placed  in  the  pelvis  to  break  up  adhesions  and  bring  the 
fundus  to  the  incision  where  it  is  grasped  and  held  with  a  volsellum. 


448 


SUEGERY    OF   THE   RECTUM    AND    PELVIS. 


A  space  on  the  anterior  surface  of  the  fundus  the  size  of  a  silver 
half  dollar  is  then  deprived  of  its  peritoneal  covering  by  scraping 
with  a  knife. 

The  form  of  suturing  will  vary  with  the  operator. 

Two  silk- worm  gut  sutures  may  be  passed  through  the  whole 


Fig.  245. 
Retroverted  Uterus  Pressing  upon  Rectum. 

thickness  of  the  abdominal  wall  and  the  uterine  tissue  under  the 
denuded  spot,  avoiding  the  uterine  cavity,  and  after  the  abdominal 
incision  has  been  closed,  these  may  be  used  to  draw  the  uterus 
firmly  against  the  abdominal  wall  and  then  tied. 

The  essential  point  of  Czerny's  method,   as  distinguished  from 
others,  is  that  the  sutures  holding  the  uterus  to  the  abdominal  wall 


FIXATION   OF   THE   UTERUS. 


449 


do  not  pass  through  the  skin.  This  plan  may  be  still  further  mod- 
ified by  using  one  continuous  suture  of  heavy  chromicized  catgut 
for  closing  the  muscular  laj^er  and  the  fascia  of  the  wound,  as  well 
as  for  supporting  the  uterus  (Fig.  246). 

Edebohls  gives  the  following  as  the  indications  for  the  operation 
of  ventral  fixation.     He  believes  that  on  account  of  the  liability  of 


TTl 


Fig.  246. 
Ventral  Fixation  of  Uterus. 


the  operation  to  cause  subsequent  difficult  labors  in  child-bearing 
women  the  operation  of  shortening  the  round  ligament  should  al- 
ways be  preferred  when  possible. 

"  The  indications  for  ventral  fixation  of  the  uterus  should  be  lim- 
ited to  the  utmost  degree  in  women  liable  to  subsequent  pregnancy. 

"  Ventral  fixation  is  never  indicated  in  uncomplicated  retrover- 
sion of  the  uterus. 

"Inability  of  an  operator  to  perform  shortening  of  the  round 
ligaments  may  be  an  indication  for  ventral  fixation,  but  not  in  the 
case  of  one  claiming  to  be  a  specialist  in  gynaecology. 


450  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

' '  Ventral  fixation  is  indicated,  as  an  adjuTiant,  in  the  perform- 
ance of  combined  operations  for  prolapsus  uteri  et  vaginge, 

"  Ventral  fixation  is  indicated  as  a  closing  step  in  all  coeliotomies 
in  which  the  adnexa  are  removed  and  the  uterus  is  left. 

"Ventral  fixation  may  be  indicated,  under  exceptional  condi- 
tions, in  cases  of  adherent  retroversion,  with  tubes  and  ovaries  in 
good  condition. 

"  Ventral  fixation  may  be  indicated  in  the  most  aggravated  cases 
of  uncomplicated  sharp  retroflexion.  The  writer  has  not  met  such  a 
case  not  amenable  to  successful  treatment  by  shortening  the  round 
ligaments. 

"Ventral  fixation  is  indicated,  under  certain  conditions,  in  cases 
of  uterus  unicornis." 

Shortening  the  Mound  Ligaments.     Alexanders  Operation. 

This  much  -  discussed  procedure  is  one  of  great  value,  having 
many  advantages  over  ventral  fixation,  the  chief  of  which  is  that  it 
leaves  the  uterus  in  much  better  position  for  future  pregnancy  and 
delivery,  should  the  patient  be  one  whose  circumstances  render  fur- 
ther child-bearing  probable  or  possible. 

The  great  objection  to  it  is  the  technical  difficulty  in  its  perform- 
ance in  unskilled  hands,  and  the  further  fact  that,  as  frequentlj^  per- 
formed, but  little  real  use  is  made  of  the  round  ligaments  for  support, 
even  after  they  have  been  exposed  at  the  external  abdominal  ring. 
At  this  point  they  are  weak,  often  difficult  to  discover,  and,  in  fact, 
in  some  patients  they  are  not  found  at  all,  the  ligament  ending  at 
the  internal  ring  and  spreading  out  upon  the  fascia  till  lost. 

When  such  is  the  case  the  inguinal  canal  should  be  freely  divided, 
as  in  Bassini's  operation  for  hernia,  and  the  round  ligament  searched 
for  within  the  canal  or  at  the  internal  ring,  where  it  is  easily  found. 

EdedohW  s  Operation. 

Edebohls  *  has  given  so  much  attention  to  this  operation,  and 
his  technique  is  so  much  more  efficient  than  that  usually  practised 
that  we  will  quote  his  own  description. 

*  American  Gynaecological  and  Obstetrical  Journal,  December,  1896. 


FIXATION    OF   THE   UTERUS.  451 

"Just  prior  to  shortening  the  round  ligaments  the  uterus  is  always 
curetted,  and  whatever  plastic  work  upon  cervix,  vagina,  and 
perineum  the  conditions  presenting  in  each  case  call  for  is  performed. 

"If  adhesions  of  the  uterus  and  adnexa  exist,  and  the  operator 
prefers  to  sever  these  adhesions  by  anterior  or  posterior  colpotomy 
rather  than  by  an  incision  from  above,  this  is  the  proper  time  to  do 
so.  At  all  events  the  operator  must  satisfy  himself  that  the  uterus 
can  be  well  anteverted  by  bimanual  manipulation  before  proceeding 
with  the  operation  of  shortening  the  round  ligaments. 

"The  uterus  is  then  allowed  to  assume  anj  position  it  may  please, 
generally  dropping  backward,  to  be  brought  into  position  at  a  later 
stage  of  the  operation  by  traction  on  the  round  ligaments.  A  little 
iodoform  gauze  is  loosely  placed  in  the  va,gina,  not  to  sustain  the 
uterus,  but  as  an  antiseptic  precaution  in  view  of  the  preceding 
curettage. 

"  The  held  of  operation  is  lathered  and  scrubbed  with  more  ten 
per  cent,  creolin-mollin,  rinsed  clean  with  sublimate  solution  (1  to 
3,000) ;  and  the  patient  is  ready  for  operation. 

"  In  shortening  the  round  ligaments  I  prefer  to  have  the  pelvis 
slightly  elevated  and  to  stand  at  the  right  side  of  my  patient,  begin- 
ning the  operation  upon  the  left  ligament. 

"An  incision  five  to  six  centimetres  long,  and  nearly  parallel  to 
Poupart'  s  ligament,  is  carried  from  the  site  of  the  internal  inguinal 
ring  downward  and  inward,  terminating  just  within  the  spine  of  the 
pubis.  Careful  location  of  the  pubic  spines,  from  the  time  of  begin- 
ning the  operation  until  the  anterior  wall  of  the  inguinal  canal  is 
opened,  is  absolutely  essential  to  success. 

"The  subcutaneous  fat  is  divided  until  the  glistening  aponeurosis 
of  the  external  oblique  muscle  is  exposed.  The  superficial  epigastric 
artery  is  frequently  divided,  and  if  so,  should  be  ligated  at  this  stage 
of  the  operation.  The  external  inguinal  ring  is  now  either  exposed 
to  view  or  located  by  the  touch. 

"A  grooved  director  is  inserted  through  the  external  ring  and 
passed  along  the  inguinal  canal,  directly  behind  the  aponeurosis  of 
the  external  oblique,  until  its  point  is  over  the  site  of  the  internal 
ring.  Cutting  upon  the  director  exactly  in  the  direction  of  the  fibres 
of  the  external  oblique  aponeurosis,  one  sweep  of  the  knife  lays  open 


452 


SURGERY    OF   THE   RECTUM   AND   PELVIS. 


the   anterior   wall   of   the  inguinal  canal    along   its   whole  length 
(Fig.  247). 

"  It  is  very  desirable  that  all  hemorrhage  should  be  controlled  be- 
fore opening  the  inguinal  canal,  otherwise  the  flow  of  blood  into  the 
latter  may  render  differentiation  of  the  round  ligament  from  the 
other  contents  of  the  canal  exceedingly  difficult.  An  assistant  ex- 
poses the  contents  of  the  canal  by  drawing  apart  the  lips  of  the  in- 


-  .  .a  e  0 


Fig.  247. 

Incision,  5  centimetres  long,  through  aponeurosis  of  external  oblique,  laying  open  inguinal  canal 
from  external  to  internal  ring  and  exposing  internal  oblique  muscle  and  round  ligament.  The  liga- 
ment is  more  or  less  concealed,  according  to  greater  or  less  development  of  internal  oblique. 

5.,  skin. 

s.  c. /.,  subcutaneous  fat. 

a.  e.  0.,  aponeurosis  of  external  oblique. 

i.  0. ,  internal  oblique. 

r.  I. ,  round  ligament. 


cision  through  the  external  oblique  aponeurosis,  with  the  aid  of 
tenacula,  blunt  hooks,  or  clamp  forceps.  The  low  fibres  of  the  in- 
ternal oblique  muscle  are  seen  crossing  the  upper  half  of  the  canal, 
filling  it  more  or  less,  according  to  the  greater  or  less  muscular  de- 
velopment of  the  individual. 

"In  a  fair  proportion  of  cases  the  lower  end  of  the  round  ligament 
is  at  once  exposed  to  view,  emerging  from  beneath  the  lower  border 
of  the  internal  oblique  ;  more  generally,  the  round  ligament  is  well 


FIXATION   OF   THE   UTERUS. 


453 


covered  and  entirely  hidden  from  view  by   the  internal   oblique 
muscle  and  an  investment  of  fatty,  areolar,  and  fibrous  tissue. 

"  Quite  frequently  some  of  the  fibres  of  the  round  ligament  are  so 
closely  interlaced  with  those  of  the  internal  oblique  muscle  that  dif- 
ferentiation and  separation  of  the  ligament  from  bundles  of  muscular 
fibre  become  difficult.  It  is  this  part  of  the  operation  which  gener- 
ally trips  the  beginner  ;  he  fails  to  find  the  ligament,  and  cannot, 
of  course,  proceed.     Experience  has  taught  me  that  the  best  method 


Fig.  348. 

Isolating  Round  Ligament  from  its  Attachments  in  Inguinal  CanaL 

S.,  skin. 

s.  c.f.,  subcutaneous  fat. 

i.  o.,  internal  oblique. 

a.  e.  0.,  aponeurosis  of  external  oblique. 

r.  I. ,  round  ligament. 


of  procedure  at  this  stage,  if  the  ligaments  are  not  at  once  exposed 
to  view  and  recognized,  is  to  search  for  them  in  the  following  man- 
ner (Fig.  248) : 

"  Ketract  the  internal  oblique  muscle  upward  and  inward  by  a 
blunt  hook  passed  beneath  the  lowermost  fibres,  and  hand  this  hook 
to  your  assistant.  Take  two  small  blunt  hooks,  one  in  either  hand, 
and  sweep  one  of  them,  point  downward  and  outward,  along  the 


464  SURGERY  OF  THE   RECTUM   AND   PELVIS. 

posterior  and  outer  walls  of  the  canal  from  the  depths  of  the  wound 
skinward,  hooking  up  the  entire  contents  of  the  canal.  By  tearing 
these  contents  apart,  more  or  less,  as  required,  by  means  of  the  two 
blunt  hooks,  the  round  ligament,  surrounded  by  fat  and  muscular 
and  tendinous  fibres  from  the  internal  oblique,  and  accompanied  by 


Fig.  249. 

Drawing  Round  Ligament  out  of  Abdomen  and  stripping  back  Investing  Peritoneum  of  Broad 

Ligament. 

i.  0. ,  internal  oblique. 

s.  c.f.,  subcutaneous  fat. 

/*.,  peritoneum. 

r.  L,  round  ligament. 

a.  e.  o. ,  aponeurosis  of  external  oblique. 

S.,  skin. 

the  ilio-inguinal  nerve,  will  soon  be  recognized,  and  can  be  followed 
along  the  canal  to  the  internal  ring.  There  the  round  ligament  is 
always  strong,  however  weak,  thin,  and  frayed-out  it  may  have  been 
found  lower  down  in  the  canal  or  at  the  external  ring. 

"The ligament  is  next  separated  from  its  investments  in  the  canal, 
leaving,  however,  the  pubic  end  attached  for  the  present.  In  this 
part  of  the  operation  great  care  should  be  exercised  not  to  divide  or 
tear  the  ilio-inguinal  nerve  which  accompanies  the  ligament,   and 


FIXATION    OF   THE    UTERUS.  455 

division  of  which  is  the  cause  of  the  various  dyssethesise  in  the 
vicinity  of  tlie  scar  sometimes  complained  of  by  patients  after 
operation. 

"In  the  canal  itself  the  ilio-iriguinal  nerve,  and  the  round  liga- 
ment are  very  intimately  connected  ;  at  the  upper  end  of  the  canal 
they  diverge,  the  nerve  to  pass  between  the  muscular  layers  and  the 
ligament  to  enter  the  internal  ring. 

"  The  ligament,  freed  from  its  surroundings  in  the  canal,  is  next 
grasped  by  the  thumb  and  forefinger  of  the  right  hand  and  cautiously 
drawn  out  at  the  internal  ring  (Fig.  249).  The  line  of  traction  should 
be  more  or  less  perpendicular  to  the  surface  of  the  abdomen  at  that 
point,  approximately  in  the  direction  of  the  intra-abdominal  portion 
of  the  ligament. 

.  "  As  the  round  ligament  emerges  at  the  internal  ring  it  is  seen  to 
carry  with  it,  in  the  form  of  an  inverted  cone,  the  investing  perito- 
neum of  the  broad  ligament,  the  point  of  reflection  of  the  latter 
being  marked  by  a  distinct  white  line  surrounding  the  round 
ligament. 

"With  the  thumb  and  forefinger  of  the  left  hand  the  investing 
peritoneum  is  stripped  or  milked  back  into  the  abdomen  as  the 
round  ligament  emerges  farther  and  farther  from  the  internal  ring. 
Occasionally  the  peritoneum  tears  in  stripping  it  back ;  this  is  a 
matter  of  no  consequence,  provided  the  asepsis  is  all  it  should  be. 

"  Should  the  ligament  not  run  freely  out  of  the  abdomen,  it  will 
be  wise,  before  employing  the  limit  of  safe  traction  force,  to  ascertain 
the  cause  by  incising  the  peritoneum  at  the  internal  ring,  bluntly 
dilating  the  latter,  and  passing  a  finger  into  the  abdomen. 

"  If  posterior  adhesions  prevent  the  uterus,  tubes,  and  ovaries 
from  coming  freely  forward,  these  may  be  separated  by  a  finger-  or 
two  hooked  behind  the  broad  ligament ;  or  if  the  infundibulo-pelvic 
ligament,  as  obtained  in  one  of  the  writer's  cases,  be  shortened  and 
thickened  as  the  result  of  previous  inflammation,  this  ligament  may 
be  stretched. 

"  The  round  ligaments  will  then  be  found  to  run  freely,  and  the 
process  of  stripping  back  the  peritoneum  is  continued  until  the  index 
finger,  passed  down  to  the  bottom  of  the  wound,  recognizes  the  im- 
pact of  the  cornu  uteri  at  the  internal  ring  when  traction  is  made 


456 


SURGERY  OF  THE  RECTUM  AND  PELVIS. 


upon  the  round  ligament.  This  constitutes  the  writer's  index  to  the 
proper  amount  of  shortening,  which,  expressed  in  figures,  will  aver- 
age about  ten  centimetres. 

"The  opposite  round  ligament  is  now  sought,  isolated,  and  drawn 
out  in  the  same  way.     Thus  far  the  ligaments  have  remained  attached 


Fig.  250. 

Deep  Tier  of  buried  running  Suture  of  forty-day  Catgut  embracing  Internal  Oblique  and 
Transversalis  Muscles,  Round  Ligament  and  Poupart's  Ligament.  Deep  part  of  uppermost  loop  of 
suture  (not  showing  in  cut)  passes  at  level  of  and  embraces  margins  of  internal  ring. 

S.,  skin. 

s.  c. /.,  subcutaneous  fat. 

a.  e.  o. ,  aponeurosis  of  external  oblique. 

i.  0.,  internal  oblique. 

r.  Z.,  round  ligament. 

P.  I.,  Poupart's  ligament. 


at  the  outer  or  pubic  ends.  These  attachments  are  now  cut  for  con- 
venience in  further  manipulation,  without,  however,  amputating  any 
part  of  the  ligament  at  present.    After  securing  the  desired  position 


FIXATION    OF   THE   UTEKUS. 


457 


of  the  uterus  by  traction  upon  the  round  ligaments,  and  adjusting 
the  latter  nicely  along  the  bottom  of  the  canal,  suture  of  the  wound 
is  in  order. 

"The  suture  material  for  the  deep  parts  consists  of  catgut.  No.  0, 


Fig.  251. 
Deep  Tier  of  Suture  drawn  home,  obliterating  Inguinal  Canal. 

&,  skin. 

s.  c.f.,  subcutaneous  fat. 

a.  e.  o.,  aponeurosis  of  external  oblique. 

i.  0.,  internal  oblique. 

P.  I.,  Poupart's  ligament. 

chromicized  by  the  writer's  method  to  resist  absorption  for  about  six 
weeks. 

"  A  half  metre  length  of  this  forty-day  catgut  is  threaded  upon  a 
full-curved  Hagedorn  needle  of  medium  size  or  under.  An  assistant, 
with  two  tenacula,  holds  wide  open  the  lips  of  the  incision  through 


458 


SURGERY   OF   THE   RECTUM   AND   PELVIS. 


the  aponeurosis  of  the  external  oblique,  so  as  to  clearly  expose  the 
deep  parts  of  the  canal,  and  especially  the  clean-cut  projecting  shelf 
of  Poupart's  ligament. 

"The  parts  are  brought  together  after  the  principle  of  Bassini's 
operation  for  the  radical  cure  of  inguinal  hernia,  with  the  exception 


Fig.  252. 

Superficial  Tier  of  Buried  Suture  of  forty-daj'  Catgut  closing  Incision  through  Aponeurosis  of  Ex- 
ternal Oblique,  restoring  Anterior  Wall  of  Canal.  The  excess  of  round  ligament  has  been  cut  away 
just  outside  of  external  ring.  The  part  protruding  through  ring,  together  with  pillars  of  external  ring 
pierced  by  lowest  loop  of  superficial  suture.  Loose  knot  at  upper  end  shows  proper  way  of  tying  buried 
catgut  knot  to  prevent  slipping.     Skin  and  fat  to  be  closed  over  all  by  subcutaneous  catgut  suture. 


that,  instead  of  the  interrupted  suture,  the  buried  running  suture  of 
forty-day  catgut,  applied  according  to  the  following  technics,  is  used. 
"  Beginning  at  the  upper  angle  and  inner  side  of  the  right  wound, 
the  first  sweep  of  the  needle  pierces  the  aponeurosis  of  the  external 
oblique,  the  underlying  internal  oblique  and  transversalis  muscles, 
the  margins  of  the  internal  ring,  the  round  ligament  as  it  emerges  be- 
tween them,  and  the  projecting  shelf  of  Poupart's  ligament.  The  suc- 
ceeding loops  of  the  deep  tier  of  sutures,  three  or  four  in  number. 


FIXATION   OF   THE   UTERUS. 


459 


pierce  the  internal  oblique  and  transversalis  muscles,  the  round  liga- 
ment, and  Poupart's  ligament.  The  last  loop,  in  addition,  penetrates 
the  outer  pillar  of  the  external  ring,  and  emerges  upon  the  outer  sur- 


FiG.  253. 
Wylie's  Operation  for  Shortening  the  Round  Ligaments. 


face  of  the  external  oblique  aponeurosis  at  the  lower  end  and  outer 
side  of  the  fascial  wound  (Figs.  250  and  251).  A  stitch  is  then  taken, 
with  still  the  same  strand  of  catgut,  piercing  the  internal  pillar  of  the 
external  ring,  round  ligament  and  external  pillar.     The  excess  of 


460  SURGERY    OF   THE   RECTUM    AND    PELVIS. 

round  ligament  is  now  cut  away  just  outside  of  the  external  ring, 
leaving  the  stump  to  plug  the  ring  (Fig.  251). 

"After  thus  obliterating  the  inguinal  canal  and  closing  both  inter- 
nal and  external  rings,  the  same  strand  of  catgut  is  continued  up- 
ward as  a  running  suture,  uniting  the  lips  of  the  incision  in  the 
external  oblique  aponeurosis,  and  closing  the  anterior  wall  of  the 
canal.  At  the  upper  end  of  the  wound  the  two  free  ends  of  catgut 
emerging  upon  the  aponeurosis  of  the  external  oblique  are  tied  to- 
gether, forming  the  only  buried  knot.  This  knot,  if  carefully  and 
tightly  tied  after  the  manner  depicted  in  the  cut — a  single  turn  in  the 
first  half  and  a  double  turn  in  the  second  half  of  the  knot — can  be 
depended  upon  not  to  slip.  The  skin  is  nicely  approximated  over 
all  by  a  subcutaneous  suture  of  ordinary  catgut  and  the  wound 
closed  without  drainage. 

"  Sterilized  dressing  applied  over  the  wounds,  and  held  in  place 
by  adhesive  plaster  and  a  double  spica  bandage,  complete  the  oper- 
ation." 

Performed  in  this  way  there  will  be  no  uncertainty  as  to  the  ef- 
fect of  the  operation  upon  the  position  of  the  uterus  or  the  power  of 
the  ligaments  to  retain  it. 

Accidents. 

In  a  few  of  Edebohls's  reported  cases  one  of  the  round  ligaments 
has  been  broken  either  in  its  length  or  at  the  cornu  of  the  uterus. 
When  broken  in  its  length,  if  enough  remains  attached  in  the  uterus 
to  complete  the  operation,  no  harm  is  done.  Otherwise  the  operation 
should  be  abandoned  and  ventral  fixation  substituted. 

He  also  reports  one  case  of  hernia  as  a  result  of  the  operation. 

Wylie^s   Operation. 

This  method  consists  in  folding  the  ligaments  upon  themselves  as 
shown  in  Fig.  253,  and  suturing  them  in  that  position  after  freshen- 
ing the  approximated  surfaces  by  scraping  off  the  peritoneal  covering 
with  a  knife. 


CHAPTER  XXIV. 

THE   RADICAL  CURE    OF  HERNIA. 

Befoee  describing  the  teclinique  of  the  operations  upon  the  differ- 
ent varieties  of  hernia,  a  few  words  should  be  given  to  general  con- 
siderations relating  to  the  operation. 

Indications  for  and  against  Operation. 

Young  children  should  not  be  operated  upon  until  after  a  truss 
has  been  tried  and  failed  to  effect  a  cure.  Most  hernisB  in  children 
are  curable  by  the  proper  use  of  a  truss. 

Age. 

Old  age  and  large  size  of  the  hernia  are  contra-indications  to  opera- 
tion, but  very  good  results  have  followed  operations  upon  old  men 
with  very  large  hernise.  Bull  and  Coley  place  the  limits  within 
which  operation  is  indicated  at  four  years  and  fifty  ;  but  four  years 
certainly  seems  too  young  to  operate,  as  a  rule,  and  fifty  not  too  old 
to  give  a  patient  the  benefits  of  an  operation  provided  he  is  other- 
wise strong  and  well. 

Irreducihility. 

Irreducibility  is  one  of  the  strongest  indications  for  radical  opera- 
tion, after  proper  efforts  have  been  made  at  reduction  and  have 
failed,  except  in  old  and  debilitated  subjects ;  but  the  operation  is 
liable  to  be  much  more  dilficult  than  in  reducible  hernia,  on  account 


462  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

of  the  adhesions  which  render  it  irreducible.  The  general  condition 
of  the  patient,  the  absence  of  visceral  disease,  and  the  ability  to  bear 
a  long  operation  must  therefore  be  taken  into  consideration. 

Obstructed  and  Inflamed  Hernia. 

In  these  cases  the  obstruction  and  inflammation  are  first  to  be 
overcome,  if  possible.  Obstruction  is  to  be  treated  by  gentle  and 
conservative  efforts  to  move  the  bowels.  These  consist  in  fluid  diet 
and  voluminous  high  enemata,  with  position  of  the  hernia  itself  to 
prevent  venous  congestion.  Should  an  evacuation  be  secured  by 
the  long  tube,  gentle  purgation  may  be  undertaken  with  salines,  and 
if  this  be  effective,  the  pain,  tenderness,  distention,  and  signs  of 
obstruction  will  rapidly  subside. 

Inflammation  is  shown  by  heat,  swelling,  and  pain  in  the  hernia. 
It  is  to  be  treated  in  much  the  same  way  as  obstruction,  except  that 
cold  local  applications  may  be  made  to  the  part.  In  both  cases 
opium  should  not  be  given,  if  for  no  other  reason  than  that  it  masks 
all  symptoms. 

In  both  obstructed  and  inflamed  hernise,  as  soon  as  it  is  evident 
that  efforts  to  relieve  the  condition  are  of  no  avail,  herniotomy  should 
be  performed,  and  after  the  reduction  of  the  hernia  the  radical  oper- 
ation for  cure  follows. 

Mortality. 

The  mortality  after  operations  for  radical  cure  in  selected  cases 
will  be  very  slight  with  good  operators — less  than  on3  and  a  half  per 
cent,  in  5,000  cases,  collected  by  Bull  and  Coley. 

Results. 

The  majority  of  cases  remain  cured  for  a  number  of  years,  and 
the  majority  of  relapses  occur  within  the  first  year.  In  these  sta- 
tistics only  the  results  of  operators  with  some  experience  should  be- 
considered. 

Suture  Material. 

It  should  be  a  rule  that  no  non-absorbable  material  be  used  in  the 
operation,  and  hence  neither  silk,  silk- worm  gut,  nor  silver  wire.    All 


THE   KADICAL   CUKE   OF   HEENIA.  463 

such  substances  are  liable  to  cause  suppurating  sinuses,  which  not 
only  interfere  with  the  result  of  the  operation,  but  may  confine  the 
patient  to  his  bed  until  the  offending  body  is  cut  for  and  found. 

The  best  of  all  material  is  that  which  is  strongest  and  will  resist 
absorption  the  longest,  and  that,  as  far  as  at  present  known,  is  kan- 
garoo tendon.  Strong  catgut  may  be  so  chromicized  as  to  resist  ab- 
sorption as  long  as  kangaroo  tendon,  but  it  must  be  very  accurately 
prepared.  Kangaroo  tendon  is  usually  to  be  counted  upon  to  hold 
for  eight  or  ten  weeks.  It  is  expensive,  as  put  wp  and  sold  in  New 
York,  as  the  supply  is  limited,  and  it  is  brought  from  Australia.  It 
is  reliably  prepared  by  one  or  two  firms  in  New  York  City,  but  the 
surgeon  will  have  difficulty  in  obtaining  it  for  his  own  preparation. 
Strands  of  even  size  and  moderate  thickness  should  be  selected,  and 
it  need  only  be  used  in  the  deep  suturing. 

Although  the  rules  given  in  the  chapter  on  general  rules  regard- 
ing operations  for  chromicizing  catgut  will  be  found  sufficient,  the 
following  by  Edebohls  are  more  accurate,  and  catgut  thus  prepared 
has  been  tested  by  him  and  found  to  resist  absorption  for  forty 
days. 

"Buy  the  raw  material,  catgut  Nos.  0  and  00,  in  coils  five  metres 
long,  of  an  importer  of  jewellers'  supplies.  Avoid  the  fine,  white, 
smooth,  alluring  catgut  sold  for  surgical  use.  The  smoothness  and 
finish  are  obtained  at  the  expense  of  strength  of  material,  the 
sand-papering  process  thinning  and  weakening  the  catgut  in 
spots,  and  the  chain  is  no  stronger  than  its  weakest  link.  Cut  and 
remove  the  small  pieces  of  catgut  tied  around  each  coil  to  keep  it 
in  shape. 

"Place  the  catgut  in  ether  to  extract  fat.  It  may  be  left  in  ether 
any  length  of  time — days  and  weeks — until  convenient  to  proceed 
with  the  further  steps  of  preparation. 

"Remove  the  catgut  from  the  ether,  and  allow  it  to  dry  thor- 
oughly. 

"To  chromicize  to  the  desired  degree,  place  the  catgut  for  thirty 
hours  in  the  following  solution  :  Bichromate  of  potash,  1.5  grammes; 
carbolic  acid,  10  grammes ;  glycerin,  10  grammes ;  water,  480 
grammes.  Dissolve  the  bichromate  of  potash  in  the  water,  then  add 
the  carbolic  acid  and  glycerin. 


464  SUEGEEY   OF   THE   EECTUM   AND   PELVIS. 

"  Before  placing  the  coils  in  the  solution  arrange  them  upon  a  cen- 
tral core  or  cylinder,  of  nearly  the  diameter  of  the  interior  of  the 
coil,  to  prevent  entangling  and  snarling  of  the  catgut  as  it  swells  and 
becomes  twisted  in  the  solution. 

"After  thirty  hours  remove  the  catgut  with  and  upon  the  core 
from  the  bichromate  of  potash  solution,  and  immediately  wind  it  upon 
a  frame,  stretching  it  pretty  taut.  I  use  a  wooden  frame,  resembling 
a  curtain-stretching  frame  in  miniature,  one  metre  in  length,  which  is 
the  length  I  find  it  convenient  to  have  catgut  sutures.  The  catgut  is 
stretched  upon  the  frame  for  the  twofold  purpose  of  convenience  in 
drying,  and  to  prevent  the  curling  and  kinking  which  obtain  when 
catgut  has  been  soaked  in  water  and  dried  without  stretching. 

''  The  drying  must  be  done  at  a  temperature  not  exceeding  40°  to 
45°  C.  If  higher  temperatures  are  risked,  the  moist  catgut  may 
gelatinize  ;  it  then  becomes  so  brittle  as  to  be  absolutely  worthless.. 
The  drying  should  be  thorough,  and  the  process  should  extend  over 
a  space  of  time  of  several  days.  If  the  least  moisture  remains  in  the 
interior  of  the  catgut,  it  will  surely  gelatinize  and  render  brittle  and 
worthless  the  catgut  when  raised  to  high  temperatures  in  the  process 
of  sterilization  to  follow.  This  thorough  drying  after  chromicizing  is, 
I  repeat,  absolutely  essential  to  obtain  a  useful  product. 

"In  chromicizing  catgut,  bear  in  mind  that  nothing  is  easier  than 
to  over-chromicize  so  as  to  make  it  practically  non-absorbable.  The 
difficulty  lies  in  chromicizing  it  to  last  just  the  required  time,  and  the 
method  just  detailed  is  the  result  of  much  and  somewhat  costly  ex- 
perimentation. Catgut  No.  0,  chromicized  as  above,  will  resist  ab- 
sorption for  about  six  weeks. 

"  The  chromicized  gut  is  now  ready  for  the  process  of  sterilization. 

"Various  methods  of  sterilization  are  at  our  disposal,  of  which  the 
writer  has  tried  only  two — dry  sterilization  at  a  temperature  up  to 
280°  F.,  and  sterilization  by  boiling  in  absolute  alcohol  under  press- 
ure. Of  the  two  he  prefers  the  latter,  as  having  yielded  him  stronger 
and  more  satisfactory  material,  without  thereby  meaning  to  impugn 
the  value  of  dry  or  of  other  forms  of  moist  sterilization. 

"After  the  chromicized  gut  is  thoroughly  dry  it  is  cut  into  pieces 
one  metre  in  length.  These  pieces  are  rolled  on  a  finger  into  small 
coils,  which  need  not  be  tied,  and  which  are  packed  nicely  into  one- 


THE   RADICAL   CURE    OF   HERNIA.  465 

ounce  glycerine  Jelly  Jars,  about  twenty  coils  to  the  Jar.  Absolute 
alcohol  (Squibb' s  99.8  per  cent.)  is  poured  over  the  catgut  in  each  jar 
until  full,  a  properly  fitting  rubber  washer  is  placed  inside  the  metal 
cap,  and  the  latter  is  screwed  down  fluid- tight.  The  glycerine  Jelly 
Jars  are  then  placed,  standing,  in  a  large  anatomical  jar  containing 
from  two  to  four  ounces  of  absolute  alcohol. 

"Two,  or  even  three,  layers  of  the  glycerin  Jelly  Jars  may  be 
placed  on  top  of  each  other  in  the  anatomical  jar.  The  cover  of  the 
latter  is  now  also  screwed  down  air  and  fluid  tight,  and  the  whole  is 
ready  for  the  sterilizer.  I  have  always  used  an  Arnold  sterilizer,  in 
which  the  large  anatomical  Jar,  filled  and  sealed  as  above,  is  placed, 
and  the  sterilizer  started. 

"  The  boiling-point  of  alcohol  is  78°  C.  The  atmosphere  of  steam 
is  100°  C,  and  the  firm  closure  of  the  small  jars,  as  well  as  of  the 
large  anatomical  Jar,  secures  the  boiling  of  the  catgut  in  absolute 
alcohol  under  pressure.  The  arrangement  probably  diminishes  the 
danger  of  explosion  and  of  ignition  of  the  alcohol  vapors.  The  cat- 
gut is  boiled  in  absolute  alcohol  under  pressure  for  five  hours,  when 
the  cover  of  the  Arnold  sterilizer  is  removed,  and  the  anatomical  jar 
with  its  contents  allowed  to  cool  gradually.  The  alcohol,  of  course, 
will  keep  on  boiling  till  the  temperature  falls  below  78°  C.  Read- 
justment of  some  of  the  rubber  washers,  and  filling  some  of  the  Jars 
with  absolute  alcohol,  to  replace  that  lost  in  the  process,  and  your 
catgut  is  ready  for  use. 

"Chromicized  catgut  prepared  in  this  way  does  not  decompose 
or  change  in  absolute  alcohol,  but  remains  strong,  sterile,  and  un- 
impaired for  years." 

The  Omentum. 

It  is  not  safe  to  tie  off  large  pieces  of  omentum  en  masse.  Most 
of  the  tissue  in  the  grasp  of  the  ligature  will  be  fat,  and  this  may 
break  down  so  quickly  that  the  ligature  ceases  to  have  any  effect  be- 
fore the  ends  of  the  blood-vessel  have  had  time  to  close. 

It  should  therefore  be  tied  off  when  irreducible  in  small  sections, 
and  not  too  near  to  the  gut,  lest  sloughing  of  the  gut  itself  should 
result. 

29 


4:66  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

After-  Treatment. 

A  truss  should  be  worn  when  the  patient  is  on  his  feet  or  at  work 
for  some  months  after  the  operation.  The  patient  may  leave  his  bed, 
when  primary  union  has  been  obtained,  in  about  two  weeks. 

Accidents. 

The  accidents  which  may  attend  the  radical  operation  are  : 
Injury  to  the  vas  deferens  from  handling  or  constriction. 
Hemorrhage  from  improper  care  of  the  mesentery. 
Sloughing  of  intestine  from  interference  with  its  mesentery. 
Localized  peritonitis  from  operation. 
Shock. 

Injury  to  the  contents  of  the  sac  in  opening  the  sac. 
Injury  to  gut  or  omentum  in  ligaturing  the  neck  of  the  sac. 
Suppuration  of  the  wound. 

BassinV s  Operation  for  Inguinal  Hernia. 

Reduce  the  hernial  contents,  if  possible,  and  locate  carefully  the 
external  abdominal  ring. 

Then  make  an  incision,  at  most  three  inches  long,  beginning  at 
the  spine  of  the  pubes  and  running  upward  and  outward  parallel 
with  Poupart's  ligament. 

Carry  the  incision  downward  till  the  fascia  of  the  external 
oblique  is  uncovered  and  the  external  ring  exposed. 

With  finger  or  grooved  director  passed  into  the  ring  for  a  guide, 
incise  the  fascia  of  the  external  oblique  for  two  inches,  thus  laying 
open  the  inguinal  canal.  Care  should  be  taken  when  the  finger  or 
director  is  passed  through  the  ring  and  along  the  canal  for  a  guide, 
that  the  hernial  sac  be  not  invaginated  and  carried  with  it,  and  thus 
laid  open  with  the  canal. 

Seize  the  two  cut  edges  of  the  fascia  with  catch  forceps,  and  with 
finger  or  handle  of  knife  separate  their  under  surfaces  from  the  con- 
tents of  the  canal,  till  the  reflexion  of  Poupart's  ligament  can  be  dis- 
tinctly seen.     Leave  forceps  attached  for  a  guide. 


THE   RADICAL   CURE   OF   HERNIA. 


467- 


Pass  a  finger  under  all  tlie  contents  of  the  inguinal  canal  and 
raise  them  out  of  their  bed.  They  will  consist  of  the  elements  of  the 
spermatic  cord  ;  more  or  less  fat,  often  considerable  ;  the  hernial  sac, 
and  perhaps  its  contents,  whether  intestine  or  omentum. 

Separate  the  cord  with  cremaster  muscles,  veins,  and  vas  defer- 


PiG.  254. 
Bassini's  Operation  for  Inguinal  Hernia. 

A,  A,  A,  subcutaneous  fatty  tissue. 

B,  upper  portion  oE  the  divided  aponeurosis  dissected  from  the  underlying  structures. 

C,  under  portion  of  the  aponeurosis  of  the  external  oblique. 
E,  cord. 

i*',  internal  oblique  muscle ;  transversalis ;  and  Cooper's  fascia. 


ens  in  one  hand,  from  ihe  hernial  sac  in  the  other,  by  gentle  pulling 
with  the  fingers. 

Open  the  hernial  sac  with  all  the  care  that  would  be  used  in  open- 
ing peritoneum  anywhere  with  a  liability  of  wounding  the  intestine. 

If  the  sac  be  empty,  pass  one  finger  into  it  down  to  its  neck,  and 
encircle  this  point  with  a  catgut  ligature  which  is  to  be  cut  short. 

The  best  way  to  avoid  tying  gut,  in  this  ligature  as  well  as  the 
sac,  is  to  have  an  assistant  tie  the  ligature  at  first  around  the  last 
phalanx  of  the  finger  held  in  the  sac,  then  as  the  ligature  is  tightened 


468 


SURGERY    OF   THE  RECTUM   AND   PELVIS. 


the  finger  is  withdrawn,  and  the  ligature  slips  between  the  end  of  the 
finger  and  any  bowel  which  may  be  in  contact  with  it. 

Amputate  the  sac  beyond  the  ligature,  leaving  a  good  stump  to 
prevent  slipping  of  the  ligature  from  intra-abdominal  pressure. 

Should  the  operator  prefer,  the  opening  into  the  sac  may  be  closed 
by  a  continuous  catgut  suture. 

Should  the  sac  when  opened  be  found  to  contain  irreducible 
omentum,  this  must  be  ligated  in  small  sections  and  amputated 
before  the  neck  of  the  sac  is  tied.  The  omentum  should  be  unfold- 
ed and  a  set  of  running  chain-ligatures  applied  across  the  part  to  be 
amputated,  each  suture  including  not  more  than  a  couple  of  inches 
of  omentum.     If  the  ligature  include  a  considerable  mass  of  the  fat 


Pig.  255. 

Bassini's  Operation  for  Inguinal  Hernia. 

The  cord  has  been  transplanted  and  the  musculo-aponeurotic  structures  on  the  inner  side  have  been 
sutured  to  Poupart's  ligament  {D)  on  the  outer  side. 

and  vessels  when  the  fat  breaks  down,  as  it  does  very  quickly  under 
the  pressure  of  the  string,  the  ligature  is  liable  to  slip,  and  fatal 
bleeding  may  result.  The  stump  of  the  mesentery  is  then  reduced  into 
the  abdomen,  after  being  washed,  and  the  neck  of  the  sac  ligatured. 


THE   RADICAL   CUKE   OF   HERNIA. 


469 


Should  the  sac  be  found  to  contain  adherent  intestine,  this  must 
be  liberated  by  blunt  or  even  sharp  dissection.  Wounds  of  the 
intestine  must  be  closed  by  Lembert's  sutures. 

Saline  solution  or  simple  sterilized  water  should  be  used  for  wash- 
ing throughout  the  operation  (Fig.  254). 

The  next  step  is  so  to  close  the  inguinal  canal  as  to  prevent  the 
recurrence  of  hernia.     With  the  cut  edges  of  the  external  oblique 


(^ 


Fig.  256. 

Bassini's  Operation  for  Inguinal  Hernia. 

Suture  of  the  Divided  Aponeurosis  over  the  Cord. 

tendon  held  well  open,  a  suture  of  kangaroo  tendon  is  passed  as' 
close  to  the  internal  abdominal  ring  as  is  possible  without  pressing 
upon  and  constricting  the  cord  as  it  passes  through  it  (Fig.  255). 

The  suture  is  passed  first  through  the  edge  of  the  muscular  fibres 
of  the  internal  oblique  and  transversalis  which  are  plainly  exposed 
in  the  wound,  and  next  through  the  reflected  portion  of  Poupart's 
ligament  and  firmly  tied.  Five  or  six  such  sutures  passed  at  dis- 
tances of  a  third  of  an  inch  will  form  a  complete  and  firm  floor  ta 
the  inguinal  canal,  and  while  they  are  being  placed  the  cord  is  to  be 
held  out  of  the  way  by  an  assistant. 


470 


SUKGERY    OF   THE   RECTUM   AND    PELVIS. 


Tlie.cord  is  now  dropped  into  its  place  upon  the  floor  thus  made, 
and  the  incision  in  the  tendon  of  the  external  oblique  is  sutured  to 
form  the  top  of  the  inguinal  canal  (Fig.  266). 

This  should  be  done  in  the  same  way  as  the  floor,  beginning  at 
the  upper  end  of  the  incision  and  carrying  the  suturing  downward  till 
only  an  external  abdominal  ring  remains  of  sufficient  size  to  permit 
the  passage  of  the  cord  without  pressure  or  strangulation.  Finally 
close  the  skin  incision  with  continuous  or  interrupted  fine  catgut. 
Dress  with  pad  of  gauze  and  firm  spica  bandage. 

Salsteacrs  Operation. 

Halstead'  s  operation  differs  from  this  in  several  particulars.  !N'ot 
only  the  aponeurosis  of  the  external  oblique,  but  the  muscular  fibres 
of  the  internal  oblique  and  transversalis  are  divided  in  laying  open 


Fig.  257. 
Halstead's  Operation  for  Inguinal  Hernia.     First  Step. 

the  canal  (Fig.  257).  After  isolating  the  cord— most  of  the  veins  are 
tied  and  are  resected— and  after  removing  the  hernial  sac,  as  in  Bas- 
sini's  operation,  a  new  canal  is  formed  by  closing  all  of  the  structures 
of  the  ring  under  the  cord  which  is  left  between  the  skin  and  the 
aponeurosis  of  the  external  oblique  (Figs.  258  and  259). 


THE   RADICAL   CURE   OF   HERNIA. 


471 


Fig.  258. 
Halstead's  Operation  for  Ingmnal  Hernia.     Second  Step. 


Fig.  2.59. 
Halstead's  Operation  for  Inguinal  Hernia.     Third  Step. 


472  SURGEKT    OF    THE   RECTUM    AND    PELVIS. 

The  operation  does  not  seem  to  possess  any  special  advantages 
as  to  results. 

We  give  the  description  in  his  own  words  : 

"Bassini's  operation  and  my  own  are  so  nearly  identical  that  I 
might  quote  his  results  in  support  of  my  own  operation.  Instead  of 
trying  to  repair  the  old  canal  and  the  internal  abdominal  ring,  I 
make  a  new  canal  and  a  new  ring.  The  latter  should  fit  the  cord  as 
snugly  as  possible,  and  the  cord  should  be  as  small  as  possible. 

"The  skin  excision  extends  from  a  point  about  five  centimetres 
above  and  external  to  the  internal  abdominal  ring  to  the  spine  of  the 
pubes. 

"The  subcutaneous  tissues  are  divided  so  as  to  expose  clearly  the 
aponeurosis  of  the  external  oblique  muscle  and  the  external  abdom- 
inal ring. 

"The  aponeurosis  of  the  external  oblique  muscle,  the  internal 
oblique  and  transversalis  muscles,  and  the  transversalis  are  cut 
through  from  the  external  abdominal  ring  to  a  point  about  two  centi- 
metres above  and  external  to  the  internal  abdominal  ring.     ' 

"The  vas  deferens  and  the  blood-vessels  of  the  cord  are  isolated. 

"  All  but  one  or  two  of  the  veins  of  the  cord  are  excised. 

"The  sac  is  carefully  isolated  and  opened,  and  its  contents  re- 
placed. 

"  A  piece  of  gauze  is  usually  employed  to  replace  and  retain  the 
intestines. 

"  With  the  division  of  the  abdominal  muscles  and  the  transver- 
salis fascia  the  so-called  neck  of  the  sac  vanishes.  There  is  no  longer 
a  constriction  of  the  sac.  The  communication  between  the  sac  and 
the  abdominal  cavity  is  sometimes  large  enough  to  admit  one's  hand. 

"The  sac  having  been  completely  isolated  and  its  contents  re- 
placed, the  peritoneal  cavity  is  closed  by  a  few  fine  silk  mattress- 
sutures,  sometimes  by  a  continuous  suture. 

"  The  sac  is  cut  away  close  to  the  sutures. 

"The  cord  in  its  reduced  form  is  raised  on  a  hook  out  of  the 
wound  to  facilitate  the  introduction  of  the  six  or  eight  deep  mat- 
tress sutures  which  pass  through  the  aponeurosis  of  the  external  ob- 
lique, and  through  the  internal  oblique,  and  transversalis  muscles 
and  transversalis  fascia  on  the  one  side,  and  through  the  transver- 


THE    RADICAL    CUKE    OF   HERNIA.  473 

salis  fascia  and  Poupart's  ligament  and  fibres  of  the  aponeurosis  of 
the  external  oblique  muscle  on  the  other. 

"The  two  outermost  of  these  deep  mattress-sutures  pass  through 
muscular  tissues  and  the  same  tissues  on  both  sides  of  the  wound. 

"They  are  the  most  important  stitches,  for  the  transplanted  cord 
passes  out  between  tliem.  If  placed  too  close  together,  the  circula- 
tion of  the  cord  might  be  imperilled,  and  if  too  far  apart,  the  hernia 
might  recur.  They  should,  however,  be  near  enough  to  each  other 
to  grip  the  cord. 

"The  precise  point  out  to  which  the  cord  Is  transplanted  depends 
upon  the  condition  of  the  muscles  at  the  internal  abdominal  ring.  If 
in  this  situation  they  are  thick  and  firm,  and  present  broad,  raw  sur- 
faces, the  cord  may  be  brought  out  here.  But  if  the  muscles  are 
attenuated  at  this  point  and  present  thin,  cut  edges,  the  cord  is 
transplanted  farther  out. 

"The  skin  wound  is  brought  together  by  buried  skin  sutures  of 
fine  silk. 

"The  transplanted  cord  lies  on  the  aponeurosis  of  the  external 
oblique  muscle  and  is  covered  by  skin  only." 

Bassinfs  Operation  for  Femoral  Hernia. 

The  incision  may  be  made  either  parallel  with  Poupart's  liga- 
ment, or  vertical  over  the  femoral  ring,  and  should  be  three  inches 
long. 

Expose  the  neck  of  the  sac  by  careful  blunt  dissection,  remember- 
ing the  relation  of  the  femoral  vein. 

After  reducing  the  hernial  contents  and  ligaturing  the  sac  as  in 
inguinal  hernia,  the  femoral  opening  is  to  be  closed  by  three  or  four 
sutures  of  kangaroo  tendon  passed  side  by  side  at  short  distances 
from  each  other  so  as  to  draw  Poupart's  ligament  downward  to  the 
pectineal  line,  and  thus  occlude  the  femoral  canal. 

Each  suture  is  passed  from  above  downward  with  a  curved 
needle,  entering  in  Poupart's  ligament,  passing  directly  down 
through  muscle  to  bone,  and  emerging  from  the  muscle  about  an 
inch  below  its  entrance. 

These  sutures  draw  Poupart's  ligament  backward  to  the  pectineal 


474 


SURGERY  OF  THE  RECTUM  AND  PELVIS. 


_;  :  _  ^__  '  \ 

Pig.  260. 
Bassini's  Operation  for  Femoral  Hernia. 


Fig.  261. 
Operation  for  Femoral  Hernia. 


THE    RADICAL    CUIIK    OK    IIKRNIA. 


475 


line,  the  first,  being  placed  near  the  spine  of  the  pubes,  the  third  one 
centimetre  from  the  femoral  vein,  and  the  second  between  the  two. 

Another  set  of  sutures  may  be  used,  three  or  four  in  number,  to 
bring  together  the  anterior  and  posterior  walls  of  the  canal.  These 
are  passed  first  through  the  falciform  fascia,  and  next  the  pectineal 
fascia,  the  lower  one  just  clearing  the  saphenous  vein. 

If  the  two  sets  are  used  all  should  be  inserted  before  the  first  set 
is  tied. 

Finally,  the  skin  wound  is  closed,  as  in  the  inguinal  operation. 


Fig.  262. 
Operation  for  Femoral  Hernia — Completed. 


A  modification  of  this  operation,  but  simpler  in  technique,  is 
shown  in  Figs.  261  and  262. 

In  it  an  incision  is  made  in  the  fascia  below  the  femoral  opening, 
so  that  it  can  be  drawn  up  to  close  the  opening. 


Ventral  Hernia. 

A  hernia  through  the  abdominal  wall,  at  some  point  other  than 
the  inguinal  rings,  may  be  due  to  a  congenital  defect,  or  to  a  wound. 


476 


SURGERY    OF    THE   RECTUM   AND    PELVIS. 


Fig.  263. 
Ventral  Hernia  between  Recti  Muscles  (Personal). 


THE    RADICAL    CURE    OF   HERNIA.  477 

The  large  majority  follow  abdominal  section  or  a  punctured  wound 
through  the  parietes.  Fig.  263  shows  a  very  large  one,  due  to  sep- 
aration of  the  recti  muscles  for  their  entire  length,  due  to  child-birth, 
and  Fig.  264,  one  due  to  an  incision  to  evacuate  pus  in  appendicitis 
nearly  twenty  years  before. 

An  old  ventral  hernia  may  be  so  large  as  to  be  incurable,  and 
death  may  result  from  the  attempt. 

First,  then,  the  operator  should  decide  whether  the  sides  of  the 
opening,  through  which  the  hernia  has  passed,  can  be  drawn  together. 
Should  such  be  the  case,  operation  is  justifiable,  and  may  be  success- 
ful ;  but  should  it  not  be  the  case,  after  the  abdomen  has  been 
opened  and  the  hernia  reduced,  the  wound  can  only  be  closed  by 
skin,  which  will  either  slough  and  allow  evisceration  and  cause  death, 
or  leave  the  patient  much  worse  than  before. 

The  abdomen  should  be  opened  over  the  most  prominent  part  of 
the  tumor.  Great  care  is  necessary  in  this  preliminary  incision,  as 
the  gut  may  be  adherent  directly  to  the  skin,  and  this  may  be  much 
thinned.  It  may  even  be  necessary  to  turn  back  a  skin  flap  in  two  or 
three  places  by  careful  dissection,  and  make  successive  efforts  to  enter 
the  free  peritoneal  cavity  before  being  successful.  When  once  the 
free  peritoneal  cavity  has  been  reached,  the  most  delicate  part  of  the 
operation  will  generally  have  been  accomplished. 

The  incision  should  next  be  enlarged  to  at  least  the  full  length  of 
the  opening  in  the  abdominal  fascia,  through  which  the  hernia  has 
escaped,  and  even  an  inch  or  so  more  at  each  end.  In  an  old  case  an 
incision  from  the  ensiform  cartilage  to  the  symphysis  may  be  none 
too  long. 

The  next  step  consists  in  freeing  adhesions  of  omentum  and  intes- 
tine from  the  hernial  sac,  and  in  effecting  reduction  of  the  hernial 
contents  within  the  abdomen.  This  may  be  a  long  and  difficult 
procedure.  Much  omentum  may  require  excision,  and  even  a  con- 
siderable piece  of  intestine  may  need  to  be  resected,  and  an  anasto- 
mosis performed. 

The  operator  is  now  ready  to  turn  his  attention  to  the  opening  in 
the  abdominal  fascia  and  prepare  it  for  suturing. 

Its  margins  should  be  distinctly  marked  out  and  freed  from  all 
fat  and  peritoneal  covering.     The  muscular  tissue  above  the  fascia 


478 


SURGERY  OF  THE  RECTUM  AND  PELVIS. 


Fig.  264. 
Ventral  Hernia  After  Operation  for  Appendicitis  (Personal). 


THE   RADICAL   CURE   OF   HERNIA.  479 

should  also  be  clearly  exposed  all  around  the  opening,  so  that  the 
abdominal  walls  may  be  approximated,  fascia  to  fascia  and  muscle 
to  muscle,  without  the  interference  of  any  fat  or  peritoneum. 

The  opening  may  then  be  closed  in  the  usual  way  with  two  rows  of 
sutures,  one  for  fascia  and  one  for  muscle,  the  former  including  the 
peritoneum.  Should  much  traction  be  necessary  to  approximate  the 
lips  of  the  opening,  additional  sutures  of  silk-worm  gut  or  silver  may 
be  used  through  the  whole  thickness  of  the  abdominal  wall,  but 
these  will  seldom  be  necessary,  and  if  introduced  they  are  not  yet 
ready  to  be  tied. 

After  the  muscular  layer  and  the  fascia  have  been  united,  the 
excess  of  skin  and  all  traces  of  the  hernial  sac  are  to  be  removed. 
Sometimes  a  considerable  ellipse  of  skin  on  each  side  of  the  incision 
may  be  removed  with  advantage,  and  the  old  hernial  sac,  which  will 
appear  as  pouches  and  sacculi  of  dense  tissue,  is  to  be  carefully  dis- 
sected out.  As  these  pockets  sometimes  extend  to  a  considerable 
extent  laterally  under  the  skin,  drainage  may  be  necessary  from  the 
bottom  of  more  than  one.  The  drainage  should  be  through  the  skin 
on  the  sides  of  the  abdomen,  away  from  and  not  through  the  median 
cutaneous  incision. 

In  many  of  these  cases,  advantage  may  be  taken  of  the  two  layers 
of  fascia,  one  above  and  one  below  the  belly  of  the  rectus  muscle. 
B\^  uniting  these  separately  a  very  strong  cicatrix  may  be  secured. 

Where  there  is  any  tension  on  the  suture  line,  it  must  be  relieved 
by  several  interrupted  sutures  of  silk-worm  gut  passed  through  the 
whole  thickness  of  the  abdominal  wall,  otherwise  failure  to  get  union 
may  be  anticipated. 

The  skin  incision  may  then  be  closed  in  the  usual  wa}^,  and  if 
deep  wire  or  silk-worm  gut  sutures  have  been  inserted  they  may  be 
fastened.  The  first  dressing  should  not  require  removal  till  union 
is  complete. 

Many  elaborate  operations  have  been  devised  for  curing  this  con- 
dition, but  the  secret  of  rapid  and  successful  work  is  to  open  the  sac 
and  get  the  hand  into  the  peritoneal  cavity  as  the  first  step  in  the 
operation.  Once  this  is  accomplished,  the  course  of  the  snrgeon  is 
plain. 

Too  much  time  may  be  spent  and  too  much  injury  may  be  done  in 


480  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

an  attempt  to  free  a  section  of  bowel  of  adhesions.  An  intestinal  re- 
section with  lateral  anastomosis  may  be  much  quicker  and  leave  the 
gat  in  better  condition. 

Umhilical  Hernia. 

This  is  generally  a  hernia  through  the  umbilical  ring,  due  to 
intra-abdominal  pressure,  as  child-bearing,  or  ascites.  The  hernia 
is  often  composed  of  omentum  alone  or  of  omentum  with  large  intes- 
tine ;  and  as  adhesions  are  very  apt  to  occur,  this  form  of  protrusion 
is  more  often  irreducible  than  reducible. 

The  operative  technique  is  the  same  as  in  ventral  hernia. 


CHAPTER   XXV. 

OPERATIONS   ON   THE   MALE    GENITOURINARY   ORGANS. 

Hypospadias  and  Epispadias. 

Just  as  the  anus  and  the  rectal  pouch  are  developed  separately 
and  a  failure  to  join  one  another  results  in  imperforate  anus,  or  abnor- 
mal situation  of  the  anal  opening,  so  are  the  glans  penis  and  spongy 
urethra  developed  separately,  and  failure  in  union  results  in  the  con- 
genital deformities  known  as  hypospadias  or  epispadias,  or  in  simple 
imperforate  urethra. 

In  both  conditions  the  termination  of  the  urethra  is  behind  the 
junction  of  the  glans  w^ith  the  spongy  portion  of  the  urethra.  In 
epispadias  the  outlet  is  on  the  roof  of  the  penis  and  the  condition  is 
usually  associated  w\t\\  exstrophy  of  the  bladder. 

Hypospadias  is  much  the  more  frequent  deformity  of  the  two.  In 
it  the  abnormal  meatus  may  be  located  anywhere  on  the  under  sur- 
face of  the  urethra  between  the  scrotum  and  the  glans,  though  the 
groove  of  the  urethra  usually  extends  as  far  forward  as  the  glans. 

The  separation  of  the  scrotum  into  two  lateral  portions,  which 
always  attends  h^^pospadias  when  the  opening  is  far  back  in  the 
urethra,  gives  rise  to  the  peculiar  appearance  of  the  genitalia  in  the 
male  so  often  mistaken  for  true  hermaphroditism.  The  only  cases  in 
which  the  sex  of  the  individual  may  be  really  difficult  or  impossible 
to  determine  before  pubert}^  are  those  of  extensive  hypospadias  asso- 
ciated with  retained  abdominal  testicles. 

Treatment. 

As  the  penis  is  usually  bent,  twisted,  or  deformed  in  hypospa- 
dias,   the  first   step  in   relieving   the  condition  usually  consists  in 


482  SURGERY    OF   THE    RECTUM    AND    PELVIS. 

incising  the  ridge  which  holds  the  deflected  glans  to  tlie  corpus  spon- 
giosum. This  often  requires  several  operations  at  intervals,  time 
being  allowed  to  watch  the  effect  of  each. 

After  the  glans  has  been  liberated  the  groove  on  its  under  surface 
is  to  be  closed  and  a  proper  meatus  constructed  by  plastic  operation. 
This  is  done  by  freshening  the  edges  of  the  groove,  and  possibly  also 
by  incising  it  on  its  upper  surface,  so  that  room  can  be  gained  for 
suture  of  the  edges  over  a  soft  rubber  catheter,  which  is  to  be  re- 
tained for  some  weeks. 

Next,  having  secured  a  meatus  and  urethra  in  the  glans,  the  re- 
mainder of  the  canal  in  the  corpus  spongiosum  is  to  be  formed  by  a 
flap  operation. 

This  is  done  by  two  parallel  incisions  about  a  third  of  an  incli 
apart,  extending  from  the  canal  already  formed  in  the  glans  back- 
ward to  the  abnormal  opening.  The  skin  on  the  sides  of  the  penis 
is  dissected  up  sufficiently  to  be  drawn  together  over  the  canal  and 
sutured  over  a  soft  rubber  catheter,  which  is  to  be  retained  until  heal- 
ing is  complete. 

Finally  the  abnormal  meatus  is  to  be  vivified  and  closed. 

The  operations  described  are  done  in  four  separate  stages,  each 
may  have  to  be  repeated  more  than  once,  and  many  months  will  be 
required. 

In  epispadias  the  operations  are  essentially  the  same,  except  when 
associated  with  exstrophy.  Here  the  attention  will  be  devoted  to  the 
main  deformit}^  and  the  probability  of  being  able  to  form  a  perfect 
urethra  is  not  great. 

Circumcision. 

The  foreskin  should  be  drawn  gently  forward  with  the  fingers  or 
with  two  pairs  of  forceps,  and  the  glans  pressed  backward  while  the 
prepuce  is  severed  with  scissors  just  in  front  of  the  glans.  No  clamp 
to  hold  the  prepuce  during  the  cutting  is  necessary. 

As  soon  as  the  parts  are  released  the  skin  will  retract  and  the 
mucous  membrane  will  be  found  too  long. 

This  must  be  slit  down  to  the  corona  and  trimmed  off  to  within  a 
quarter  of  an  inch  of  its  attachment  all  around  to  the  frsenum.     If 


OPEEATIONS   ON   THE   MALE   GENITO-URINARY   ORGANS.  483 

adhesions  exist  between  it  and  tlie  glans  they  must  be  dissected  loose 
or  broken  by  blunt  dissection. 

The  operation  is  completed  by  stitching  the  cut  edge  of  the  skin 
to  the  cut  edge  of  the  mucous  membrane  with  fine  catgut  interrupted 
sutures,  about  four  to  the  inch,  and  dusting  the  wound  with  aristol. 

Park  recommends  a  very  neat  dressing.  "A  rubber  condom  (the 
narrow  neck  of  which  is  split  to  avoid  constriction)  is  drawn  over  the 
hole.  The  tip  of  this  condom  is  tlien  cut  off  and  the  edges  fastened 
to  the  surface  of  the  gland  with  collodion,  to  prevent  leakage  of 
urine  into  the  dressing." 


Amputation  of  the  Penis. 

About  the  only  indication  which  ever  arises  for  amputation  of  the 
penis  is  the  presence  of  epithelioma.  Should  there  be  sufficient 
room  behind  the  growth  (one  lialf  or  three-quarters  of  an  inch)  either 
a  circular  or  a  Hap  operation  may  be  done.  In  other  cases  the  organ 
must  be  completely  extirpated. 

The  circular  amputation  consists  in  making  a  skin  incision  com- 
pletely around  the  organ,  and  then  dividing  the  corpus  spongiosum 
and  the  corpora  cavernosa  at  different  levels,  the  former  being  left 
enough  longer  than  the  latter  so  that  the  urethra  may  be  stitched  to 
the  edges  of  the  skin  incision. 

The  flap  operation  is  rather  more  elaborate,  and  consists  in  mak- 
ing a  dorsal  and  lateral  skin  flaps  down  to  the  tunica  albuginea. 
The  skin  is  first  made  tense  by  traction  on  the  prepuce  so  that  it  will 
retract  slightly  after  being  cut.  The  knife  is  then  passed  between 
the  corpus  spongiosum  and  the  corpora  cavernosa,  and  the  former  is 
cut  across  by  an  incision  slanting  forward.  The  corpora  cavernosa 
are  then  divided  on  a  level  with  the  skin  flaps,  and  dissected  away 
from  the  spongiosum  and  urethra.  The  end  of  the  urethra  should 
be  enough  longer  than  the  corpora  cavernosa  so  that  it  can  be  turned 
upward  and  brought  out  through  an  incision  in  the  dorsal  flap. 

After  suturing  the  skin  incisions,  the  urethra  is  slit  open  and  its 
edges  sutured  to  the  edges  of  the  incision  in  the  skin  flap. 

Bleeding  may   be  prevented  by  the  use  of  an  elastic   bandage 


484  bURGEEY    Oi'    THE    KECTUM    AND    PELVIS. 

around  the  base  of  the  organ  during  the  operation  ;  and  a  soft  rub- 
ber catheter  should  be  left  in  the  bladder  for  the  first  few  days. 

Extirpation  of  the  Penis. 

In  cases  in  which  the  malignant  disease  has  involved  so  much  of 
the  organ  that  amputation  is  no  longer  possible,  the  whole  penis  may 
be  extirpated. 

With  the  patient  in  the  dorsal  position  an  incision  is  made  around 
the  base  of  the  penis,  extending  down  the  whole  length  of  the  scro- 
tum. 

The  scrotum  is  next  divided  into  its  two  halves  by  blunt  dissec- 
tion down  to  the  corpus  spongiosum. 

The  urethra  is  next  to  be  cut  across  behind  the  bulb.  This  is  best 
done  by  passing  a  sound  down  to  the  triangular  ligament,  and  pass- 
ing the  knife  between  the  corpora  cavernosa  and  the  corpus  spongio- 
sum with  the  sound  for  a  guide.  When  the  sound  is  withdrawn,  the 
urethra  is  cut  across  and  dissected  out  as  far  back  as  the  triangular 
ligament. 

The  penis  is  then  dissected  out  as  far  back  as  the  attachments  of 
the  crura  to  the  pubic  arch  with  a  knife,  and  the  attachments  to  the 
bone  are  torn  away,  partly  with  the  knife  and  partly  by  blunt  dis- 
section. 

The  edges  of  the  skin  incision  are  then  united,  the  end  of  the  ure- 
thra being  stitched  to  the  incision  at  about  the  middle  of  the  scrotum. 

A  catheter  should  be  left  in  the  bladder. 

Laceration  of  the  Urethra. 

The  symptoms  upon  which  the  diagnosis  of  this  injury  must  de- 
pend are : 

Pain. 

Bloody  urine. 
-  Retention  of  urine. 

Extravasation. 

When  the  laceration  is  in  front  of  the  triangular  ligament,  the 
extravasation  will  manifest  itself  in  the  perineum   and  scrotum. 


OPERATIONS   ON   THE   MALE   GENITO-UEINARY    ORGANS.  485 

When  tlie  laceration  is  behind  tlie  ligament,  the  extravasation  may 
also  appear  in  the  perinenm,  but  is  also  apt  to  invade  the  pelvic  cel- 
lular tissue  and  may  lirst  appear  over  the  symphysis. 

Treatment. 

Laceration  with  an  external  wound  allowing  the  escape  of  urine 
should  be  sutured  over  a  catheter.  The  wound  may  be  enlarged  for 
this  purpose  and  the  suturing  done  with  fine  catgut. 

If  a  catheter  cannot  be  passed  into  the  torn  proximal  end,  and  if 
there  is  extravasation  of  urine  into  the  tissues  around  the  wound, 
external  perineal  urethrotomy  should  be  performed. 

Retrograde  catheterism  is  then  possible,  and  the  proximal  end  of 
the  urethra  can  be  found. 

The  treatment,  when  there  is  no  external  wound,  will  depend 
upon  the  presence  or  absence  of  extravasation. 

If  a  catheter  can  be  passed  and  retained,  or  even  if  the  water  be 
drawn  at  frequent  intervals,  operative  interference  may  be  unneces- 
sary. At  the  first  sign  of  extravasation  a  free  incision  must  be  pro- 
vided for  the  escape  of  urine. 

When  the  wound  is  in  the  penile  urethra,  the  inability  to  pass  a 
sound  beyond  it,  or  the  swelling  caused  by  the  escape  of  urine 
around  it,  may  indicate  its  location  ;  and  it  may  be  converted  into 
an  open  wound,  and  treated  as  such  with  suture. 

In.  wounds  of  the  deep  urethra  with  extravasation,  external  peri- 
neal urethrotomy  is  the  first  desideratum,  the  laceration  being  sub- 
sequently sutured  if  possible. 

Misplaced  Testicle. 

One  or  both  testicles  may  be  arrested  anywhere  in  the  course  of 
their  descent  from  the  lower  edge  of  the  kidney  to  the  internal  ab- 
dominal ring  ;  or,  having  reached  the  internal  ring,  may  be  retained 
within  the  canal  or  may  lie  in  some  abnormal  position  outside  of  it, 
never  reaching  their  proper  place  in  the  scrotum. 

The  former  condition  is  known  as  cryptorchidism,  the  latter  as 
ectopia. 


486  SUKGERY    OF   THE   RECTUM   AND   PELVIS. 

When  retained  in  the  abdomen  the  organ  may  occwpy  almost  any 
position  and  may  be  freely  movable.  'No  surgical  interference  is  nec- 
essary. 

When  retained  in  the  inguinal  canal,  or  misplaced  outside  of  it, 
the  organ  is  especially  subject  to  frequent  attacks  of  inflammation, 
is  always  liable  to  injury,  and  is,  moreover,  liable  to  cancerous  de- 
generation. Such  patients  are  in  addition  generally  sterile  when 
both  organs  are  affected,  although  normal  desire  and  erection  may 
remain.  The  sterility  is  developed  gradually  as  age  advances,  the 
organ  becoming  fibrous  and  ceasing  to  secrete  healthy  spermatozoa. 

Retention  may  be  inguinal  or  scrotal ;  displacement  femoral, 
pubic,  or  perineal.  In  all  cases  the  organ  should  be  transplanted 
to  the  scrotum  if  possible,  or  else  removed,  to  prevent  injury  and  de- 
generation. 

In  retention  within  the  inguinal  canal,  an  incision  is  made  over 
the  external  ring  and  downward  into  the  scrotum. 

The  testicle  is  grasped  b}^  the  fingers  and  freed  from  all  attach- 
ments except  the  spermatic  cord. 

Should  the  vaginal  pouch  of  peritoneum  exist  and  communicate 
with  the  general  peritoneal  cavity,  it  should  be  cut  across  and 
sutured  as  in  the  radical  operation  for  hernia. 

The  fibres  of  the  cremaster  will  require  division  to  allow  of  the 
descent  of  the  testicle  and  prevent  its  reascent  after  being  fastened 
below. 

Having  freed  the  organ  from  its  attachments  till  it  reaches  easily 
and  without  tension  to  its  natural  position,  it  is  sutured  to  the 
bottom  of  the  scrotal  incision  by  fine  catgut  passing  through  the 
tunica  albuginea. 

The  external  abdominal  ring  and  the  inguinal  canal  should  then 
be  closed  by  sutures,  allowing  only  sufiicient  room  for  the  cord  and 
preventing  both  future  hernia  and  retraction  of  the  testicle  to  its  ab- 
normal position. 

The  wound  should  be  aseptic  and  no  drainage  necessary.  Sub- 
sequent retraction  as  far  as  the  external  ring  is  very  apt  to  render 
the  operation  of  little  practical  benefit. 

Perineal  Malposition  is  the  most  troublesome  of  all  the  varieties, 
especially  in  these  days  of  the  wheel. 


OPERATIONS    ON   THE    MALE    GENITO-UEINARY    ORGANS.  487 

The  testicle  should  be  pushed  as  far  forward  as  possible  without 
force,  and  an  incision  made  between  it  and  the  scrotum  while  held  in 
this  position. 

The  fibrous  attachments  which  prevent  further  descent  are  then 
to  be  cut  and  the  organ  sutured  as  before. 

A  long  scrotal  incision  may  be  avoided  by  invaginating  the  bot- 
tom of  the  scrotum  through  a  short  incision  in  its  upper  part  and 
doing  the  suturing  while  the  invagination  is  maintained.  Reduction 
of  the  invagination  draws  the  testicle  into  its  proper  place  in  the 
scrotum. 

Pubic  ectopia  is  rare,  and  is  treated  in  the  same  way. 

Femoral  ectopia  is  the  most  difficult  to  replace.  An  effort  may  first 
be  made  to  reduce  the  organ  to  the  abdominal  cavity  and  retain  it 
there  by  closure  of  the  femoral  opening,  as  in  the  operation  for  hernia. 
Failure  in  this,  or  subsequent  attacks  of  inflammation  in  the  organ, 
should  lead  to  its  removal. 

Castration. 

The  incision  should  begin  fully  an  inch  below  the  external  ab- 
dominal ring  and  be  long  enough  to  allow  of  enucleation  of  the  tes- 
ticle or  tumor  for  which  the  operation  is  performed. 

When  the  testicle  alone  is  to  be  removed  it  is  easily  turned  out 
of  its  bed ;  when  a  tumor  and  adhesions  are  present  some  dissection 
may  be  necessary. 

The  cord  and  its  vessels  may  safely  be  ligated  en  masse  and  cut 
across  sufficiently  far  below  the  ligature  so  that  the  latter  will  not 
slip.  As  the  mucosa  of  the  vas  deferens  may  be  septic,  the  stump 
should  be  cauterized  with  pure  carbolic  acid. 

Should  there  be  sinuses  running  from  the  testicle  to  the  skin  these 
should  be  excised,  and  the  cutaneous  incision,  which  in  such  cases 
may  be  elliptical  and  include  a  considerable  section  of  the  scrotum, 
should  be  closed  with  fine  catgut. 

Whether  or  not  drainage  be  employed  must  depend  upon  whether 
the  operation  has  been  aseptic  or  the  wound  been  fouled  with  the 
contents  of  the  tumor. 


4b8  SUUGEUY    OF   THE   RECTUM   AND   PELVIS. 

Hydrocele. 

There  are  three  recognized  methods  of  treatment.: 

Incision. 

Excision. 

Injection. 

The  incision  should  be  free  and  the  edges  of  the  sac  should  be 
stitched  to  the  skin  to  keep  it  open  and  prevent  infiltration  of  the 
scrotal  layers.     The  sac  should  be  packed  with  iodoform  gauze. 

In  excision  the  sac  is  peeled  out  of  its  bed.  This  can  generally  be 
done  completely  without  evacuating  its  contents,  and  the  incision 
may  be  closed  immediately,  with  slight  drainage  to  allow  of  the 
escape  of  blood.  This  is  the  only  method  of  treatment  by  which  a 
radical  cure  can  be  promised. 

When  injection  is  used  the  fluid  may  be  either  strong  carbolic 
acid  or  tincture  of  iodine.  Neither  is  reliable  and  both  are  danger- 
ous, because  the  amount  of  inflammation  excited  either  may  not  be 
sufficient  to  effect  a  cure  or  may  be  so  great  as  to  cause  sloughing. 

The  main  point  in  technique  is  to  be  sure  that  the  carbolic  acid 
(95  per  cent.)  is  placed  within  the  sac  of  the  hydrocele,  and  that  the 
cannula  has  not  slipped  out  of  the  sac  into  the  tissue  of  the  scrotum. 

The  sac  should  first  be  emptied  of  its  contents  through  a  large 
hypodermic  needle  and  cannula.  Twenty  drops  of  the  carbolic  acid, 
or  a  drachm  of  tincture  of  iodine,  is  a  sufficient  quantity,  and  this 
should  be  thoroughly  spread  around  the  sac  with  the  fingers. 

There  will  be  some  swelling  as  a  result  of  the  application,  but  this 
in  a  few  days  should  subside.  While  it  remains  the  patient  should 
wear  a  suspensory  bandage  and  keep  comparatively  quiet. 

Should  suppuration  or  sloughing  occur  it  must  be  met  by  free  in- 
cisions. 

It  is  needless  to  say  that  all  of  these  procedures  should  be  done 
with  full  antiseptic  details. 

Varicocele. 

Two  operations  are  recognized,  one  subcutaneous,  the  other  open. 
The  former  is  usually  done  with  a  sharp  pointed  ligature- carrier, 
although  a  strong  straight  needle  will  answer  every  purpose. 


OPERATIONS    ON   THE   MALE   GENITO-UKIJsTAEY   ORGANS.  489 

Subcutaneous  Operation. 

Separate  with  care  the  vas  deferens  from  the  enlarged  veins  and 
hold  the  former  firmly  between  the  thnmb  and  finger  of  the  left 
hand. 

Transfix  the  scrotum  between  the  vas  deferens  and  the  veins  from 
before  backward  with  the  ligature-carrier  or  needle,  armed  with  stout 
silk,  and  draw  the  silk  through  the  puncture  and  leave  it. 

Withdraw  the  ligature-carrier  and  transfix  the  scrotum  again  ex- 
actly as  before  and  through  the  same  openings,  with  the  carrier  un- 
armed ;  only  passing  this  time  on  the  other  side  of  the  veins.  Fit 
the  ligature  into  the  carrier  a  second  time  and  withdraw  the  needle. 

In  this  way  the  veins  to  be  tied  will  have  been  encircled  by  the 
ligature,  which  will  enter  and  return  through  the  same  opening  in  the 
front  of  the  scrotum. 

The  same  procedure  should  be  used  at  two  points,  one  near  the 
testicle  and  another  higher  up,  nearer  the  cord,  at  least  an  inch  dis- 
tant from  the  first  one. 

Tie  both  ligatures  securely  and  the  operation  is  completed.  Dress 
antiseptically,  and  wait  till  the  ligatures  separate  and  can  be  pulled 
away. 

Open  Method. 

With  an  assistant  holding  the  testicle  down  on  the  affected  side 
so  as  to  put  the  scrotum  on  the  stretch,  make  a  longitudinal  incision 
about  two  inches  long  over- the  veins  to  be  removed.  Dissect  down 
till  the  veins  are  exposed,  and  grasp  the  mass  between  the  thumb  and 
finger. 

With  the  fingers  gently  separate  the  vas  deferens  from  tlie  mass 
of  enlarged  veins  and  tie  the  latter  in  two  places  about  an  inch  and 
a  half  apart. 

Cut  one  end  of  each  ligature  close  to  the  knot,  and  tie  the  other 
ends  together.  In  this  way  the  cut  stumps  of  the  veins  are  brought 
into  contact  and  the  corresponding  testicle  is  well  raised.  Cut  the 
ends  of  knot  short  and  close  the  cutaneous  incision  with  fine  gut. 

Injury  to  the  vas  deferens  in  these  operations  will  cause  impo- 
tence on  the  injured  side. 


490  SURGEllY    OF    THE    RECTUil   AXD    PELVIS. 

Ligation  of  the  spermatic  artery  may  cause  gangrene  of  the 
testicle. 

If  the  veins  are  tied  only  high  up  in  the  scrotum  they  will  still  fill 
from  below,  and  the  patient  will  experience  but  little  relief. 

]N"ot  all  of  the  veins  should  be  tied,  lest  atrophy  of  the  testicle 
should  result. 

Internal   Urethrotomy. 

The  old  operations  of  internal  urethrotomy  for  strictures  deep  in 
the  urethra  have  been  very  nearly  abandoned  on  account  of  the 
danger  of  septic  infection  and  hemorrhage  inherent  in  them.  The 
most  conservative  operators  now  only  use  the  operation  upon  strict- 
ures within  half  an  inch  of  the  meatus,  and  prolong  the  incision 
through  the  meatus  itself,  thus  providing  for  free  drainage.  Such  an 
operation  needs  no  special  urethrotomy,  a  blunt-pointed  straight 
bistoury  answering  every  purpose. 

In  strictures  deeper  in  the  penile  urethra  an  external  perineal 
urethrotomy  should  first  be  performed,  after  which  the  stricture 
tissue  is  freely  divided  with  a  bistoury  if  it  can  be  reached,  or  with 
a  urethrotome  if  it  cannot.  In  this  way  infection  of  the  urethral  in- 
cision is  prevented  by  the  free  drainage  through  the  perineum. 

External  Perineal  TJretTir atomy. 

The  most  frequent  indications  for  this  operation  are  : 

Stricture  of  the  urethra. 

Drainage  of  the  bladder. 

Vesical  calculus. 

Dilatation  of  the  neck  of  the  bladder. 

Retention,  or  extravasation  of  urine. 

The  operation  is  done  preferably  with  a  grooved  staff  in  the  ure- 
thra. In  cases  of  impassable  stricture,  the  operation,  however,  must 
be  done  without  a  guide,  and  becomes  much  more  difficult  and 
delicate. 

Operation  loith  a  Staff. 

The  patient  is  placed  in  the  dorsal  position,  with  legs  well  elevated 
and  held  either  in  Edebohls's  supports  or  by  assistants.    A  sand-bag 


OPERATIONS    ON   THE    MALE    GENITO-URIXAEY    ORGANS.  491 

should  be  placed  under  the  back  to  bring  the  perineum  well  up  off 
from  the  table. 

The  grooved  staff  is  passed  into  the  bladder  and  held  up  closely 
under  the  arch  of  the  pubes  by  a  special  assistant. 

A  long  delicate  knife  with  thin  blade  is  used  to  make  an  incision 
through  the  skin  in  the  raphe  of  the  perineum,  which  is  carried 
down  till  the  staff  is  reached  in  the  membranous  portion  of  the 
urethra. 

The  incision  in  the  urethra  should  not  exceed  three-quarters  of 
an  inch  in  length.  The  finger  follows  the  withdrawal  of  the  knife 
and  is  pushed  steadily  along  the  staff  till  it  enters  the  neck  of  the 
bladder. 

The  staff  is  then  withdrawn  and  the  neck  of  the  bladder  dilated 
with  the  finger  to  the  extent  thought  necessary. 

In  old  cases  of  spasm  of  the  neck  of  the  bladder,  the  dilatation 
should  be  thorough.  In  cases  of  stone,  too  much  anxiety  should 
not  be  felt  to  get  a  perfect  specimen  through  the  incision  without 
crushing. 

The  points  to  be  avoided  in  this  incision  are  the  bulb  of  the  ure- 
thra and  the  rectum  ;  the  former  in  front,  and  the  latter  behind,  and 
a,  very  pretty  toiur  de  main  is  to  enter  the  knife  in  the  skin  at  the 
proper  point  in  the  perineum,  with  the  linger  in  the  rectum  as  a 
guide,  and  by  a  single  puncture,  without  a  staff  or  any  dissection, 
evacuate  urine  ;  then  enlarge  the  incision  through  the  apex  of  the 
prostate  and  the  membranous  urethra  as  the  blade  is  withdrawn,  and 
introduce  the  finger  for  dilatation. 

In  cases  where  the  channel,  through  an  impassable  stricture,  can- 
not be  found  even  by  dissection,  this  feat  may  still  be  possible,  and 
reverse  catheterism  through  this  incision  may  be  made  to  take  the 
place  of  a  supra-pubic  cystotomy. 

External  Urethrotomy  without  a  Guide. 

A  staff  or  ordinary  sound  is  passed  down  to  the  stricture  and 
held  in  contact  with  it  by  an  assistant  who  also  draws  the  scrotum 
upward  out  of  the  way,  and  who  should  have  nothing  else  to  do. 

The  end  of  the  staff  is  then  cut  down  upon  and  exposed  in  the 

31 


492  SURGEKY    OF    THE    RECTUM    AND    PELVIS. 

wound,  and  two  sutures  of  fine  silk  are  introduced  ;  one  into  the 
mucous  membrane  of  tlie  urethra  on  each  side  of  tlie  incision  for 
guides  and  retractors. 

The  face  of  tlie  stricture  is  thus  exposed  by  laying  open  the  ure- 
thra at  a  point  just  in  front  of  it,  and  tlie  staff  may  be  discarded  as 
being  of  no  further  use. 

A  long  and  careful  dissection  to  get  through  the  stricture  may 
next  be  necessary. 

The  point  most  to  be  avoided  is  cutting  through  the  urethra  at  a 
point  opposite  the  first  incision,  and  carrying  the  dissection  upward, 
farther  and  farther  away  from  the  opening  through  the  stricture. 

There  always  is  an  opening  through  the  stricture,  and  sometimes 
a  very  fine  silver  probe  will  detect  it.  At  others,  pressure  upon  the 
bladder  will  force  out  a  drop  of  urine,  which  will  be  a  sufficient  indi- 
cation. 

Irrigation  with  very  hot  water  will  sometimes  clear  the  field  of 
operation  by  showing  the  difference  between  the  stricture  tissue  and 
the  healthy  urethra  in  front  of  it. 

Delicate  and  careful  dissection  will  seldom  fail  to  be  successful. 
^Nevertheless,  this  has  occurred  to  good  surgeons.  In  such  cases 
reverse  catheterization  by  means  of  a  supra-pubic  incision  is  the  way 
out  of  the  difficulty.  A  sound  is  thus  brought  down  to  the  perineal 
incision  from  the  opposite  side  of  the  stricture,  and  with  such  aid, 
the  channel  may  be  re-established,  if  in  no  other  way,  at  least  by 
resection  of  the  entire  stricture  tissue. 

.  Drainage. 

A  short  rubber  tube  may  be  passed  into  the  bladder  and  fastened 
with  a  safety-pin  to  the  incision,  a  catheter  may  be  passed  from 
the  meatus  and  tied  in,  or  the  operator  may  trust  to  keeping  the 
wound  open  by  the  occasional  introduction  of  a  finger  into  the 
bladder. 

On  the  whole,  this  is  preferable  as  causing  the  least  pain,  but  in 
cases  of  urethral  fever  or  of  purulent  cystitis,  the  catheter  may  be 
necessary,  simply  as  affording  a  channel  for  frequent  medication  of 
the  bladder  with  some  one  of  the  remedies  for  this  condition. 


OPEKATIONS    ON   THE   MALE   GENITO-URINAKY    ORGANS.  493 

Acute  Prostatitis. 

This  is  generally  the  result  of  gonorrhoea  or  one  of  its  complica- 
tions, although  it  may  result  from  traumatism,  as  with  a  sound,  or 
from  excessive  sexual  indulgence.  The  inflammation  may  be  con- 
fined to  the  follicles  or  invade  the  entire  parenchyma,  in  which  lat- 
ter case  it  usually  proceeds  to  suppuration. 

Symptoms. — One  of  the  first  and  most  pronounced  symptoms  of 
the  condition  is  pain  in  the  rectum  and  perineum.  With  this  there 
is  pain  in  the  loins,  rectal  and  vesical  tenesmus,  a  sense  of  fulness  in 
the  bowel,  as  though  some  foreign  substance  were  there,  with  heat 
and  throbbing  in  the  part.  In  some  cases  there  may  be  complete  re- 
tention of  urine,  with  fever  and  constitutional  disturbance. 

Digital  examination  by  the  rectum  shows  at  once  the  increased 
size  of  the  organ,  which  is  extremely  sensitive  to  pressure,  and  pro- 
jects far  enough  into  the  bowel  to  form  an  obstacle  to  the  finger. 

The  inflammation  may  subside  in  the  course  of  one  or  two  weeks 
under  proper  local  and  constitutional  treatment.  If  pus  is  formed  it 
will  usually  evacuate  itself,  if  left  to  nature,  b}^  the  rectum,  bladder, 
or  perineum,  although  it  may  take  an  upward  course  into  the  pelvis. 
After  spontaneous  rupture  there  is  an  immediate  relief  of  all  symp- 
toms. 

Treatment. — The  treatment  should  be  rest  in  bed,  hot  fomenta- 
tions over  the  perineum  and  bladder,  alkalies  by  the  mouth,  and  suf- 
ficient anodynes  to  allay  the  constant  desire  to  urinate  and  defecate. 
When  pus  can  be  made  out  in  the  body  of  the  organ  by  rectal  ex- 
amination it  should  at  once  be  evacuated  by  incision  through  the 
perineum,  and  not  by  puncture  through  the  rectum,  after  which  the 
abscess  cavity,  unless  very  large,  wall  usually  granulate  rapidly. 

Periprostatic  Abscess. 

In  this  form  of  disease  the  suppuration  extends  from  the  pros- 
tate to  the  surrounding  cellular  tissue,  and  may  involve  any  part  of 
the  pelvic  connective  tissue.  In  such  cases,  although  the  symptoms 
may  be  less  intense,  the  possible  injury  to  the  pelvis  is  much  greater, 
and  the  pus  should  be  evacuated  by  free  incision  as  soon  as  its  pres- 


494  SURGEKY    OF    THE    RECTUM   AND    PELVIS. 

ence  is  suspected,  otherwise  great  damage  may  be  done  in  the  pelvis 
and  life  be  endangered. 

The  prognosis  is  grave  in  all  cases,  for  although  early  incision 
may  prevent  serious  consequences,  these  are  the  cases  that  end  in 
recto-vesical  fistula,  stricture  of  the  urethra  and  rectum,  and  pro- 
longed suppuration  with  discharge  of  pus  by  the  rectum  or 
bladder. 

In  these  cases  also  every  effort  should  be  made  to  evacuate  the 
pus  through  a  median  perineal  incision  ;  but  when  it  is  pointing  into 
the  rectum  it  should  be  quickly  evacuated  there,  unless  reached  by 
the  perineal  route,  to  prevent  further  damage  to  the  pelvic  connective 
tissue,  and  possible  rupture  into  the  bladder. 

As  far  as  possible  all  sloughing  tissue  should  be  broken  down 
with  the  finger  and  drainage  established.  After  which  the  abscess 
cavity  should  be  irrigated  frequently  with  1  to  5,000  bichloride. 

Chronic  Prostatitis. 

This  is  due  to  the  same  causes  as  the  acute  process.  It  may  be  a 
sequel  of  the  acute  form  of  the  disease,  or  may  be  chronic  from  the 
start.  It  may  result  from  a  chronic  urethritis  or  cystitis,  or  from 
prostatic  calculi,  or  from  any  cause  which  keeps  up  an  habitual  con- 
gestion of  the  parts.  It  is  not  to  be  confounded  with  enlargement  or 
hypertrophy  of  the  organ. 

Symptoms. — These,  although  of  the  same  general  character  as  in 
acute  cases,  are  less  marked.  There  is  dull  pain  in  the  rectum  and 
over  the  bladder ;  a  sense  of  fulness  in  the  rectum  and  perineum ; 
pain  in  the  glans  penis,  back,  and  sacrum,  and  inability  to  sit  with 
comfort  because  of  pressure  on  the  perineum. 

In  addition  to  this  there  is  disturbance  of  the  sexual  f-unction. 
Desire  may  be  lost,  or  ejaculation  may  be  premature,  and  on  this  ac- 
count the  patient  is  often  hypochondriacal. 

The  examination  of  the  organ  by  the  rectum  will  reveal  its  en- 
larged and  sensitive  condition. 

Treatment  consists  in  removal  of  the  cause  if  it  can  be  discovered, 
as  in  gonorrhoea,  stricture  of  the  urethra,  or  sexual  excess.  In  ad- 
dition to  this  the  use  of  large  cold  sounds  and  the  stripping  of  the 


OPERATIONS    OX   THE    MALE    GENITO-UEIXART    ORGANS. 


495 


organ  with   the  finger  will  give  great  relief.     Counter  irritation  by 
blistering  the  perineum  is  valuable. 

The  disease  is  often  associated  with  hemorrhoids,  and  the  removal 
of  these  may  effect  a  cure.  More  frequently  the  disease  is  mistaken 
for  some  affection  of  the  rectum,  and  the  treatment  is  devoted  entirely 
to  the  wrong  channel. 

Enlargement  or  Hypertroiohy  of  the  Prostate. 

These  terms,  although  generally  used  to  express  the  same  condi- 
tion, are  not  synonj'mous. 

The  enlargement  is  always  diffuse ;  the  hypertrophy  always 
localized. 

It  is  probable  that  the  diffuse  enhiigement  is,  at  least  in  most 
cases,  the  result  of  a  previous  chronic  inflammation.     The  localized 


Fig.  265. 

Hypertrophy  of  Prostate. 

hypertrophies  may  result  from  the  diffuse  enlargement  or  may  par- 
take of  the  character  of  distinct  tumors. 

The  disease  is  a  very  gradual  one,  and  its  seriousness  is  due  solely 
to  its  interference  with  urination,  thus  causing  retention,  cystitis, 
dilatation  of  the  bladder  and  ureters,  suppurative  disease  of  the  pelvis 
of  the  kidney,  degeneration  of  the  wall  of  the  bladder ;  and  finally 
septic  poisoning. 


496  SURGERY    OF   THP:    RECTUM    AIS'D    PELVIS. 

Sjniptoms. — These  are  first  an  increased  frequenc}^  in  micturition, 
especially  at  night,  with  feeble  expulsive  power,  and  difficulty  in 
starting  the  stream.  To  these  are  sooner  or  later  added  those  due  to 
catarrh  of  the  bladder,  and  finally  those  due  to  retention  of  urine. 

The  diagnosis  is  made  b}^  rectal  examination  for  increased,  pain- 
less enlargement  of  the  organ,  and  by  the  use  of  the  catheter  to  de- 
tect residual  urine.  The  differential  diagnosis  will  lie  between  cancer 
tuberculosis,  and  vesical  or  prostatic  calculus. 

Treatment  is  directed  eitlier  to  relieving  the  retention  and  the 
chronic  cystitis,  and  preventing  septic  poisoning,  or  to  the  radical 
cure  of  the  disease  by  supra-pubic  cj^stotomy,  perineal  urethrotomy 
with  prolonged  drainage,  prostatectomy,  or  castration. 

Operation  is  always  indicated  when  the  patient  cannot  endure 
catheter-life,  when  it  is  impossible  for  him  to  pass  the  catheter  him- 
self and  wash  out  the  bladder,  and  when  cystitis  is  threatened  or 
actually  exists.  ' 

Prostatectomy. 

Exactly  the  same  method  is  employed  as  described  under  supra- 
pubic cystotomy  up  to  the  point  where  the  bladder  has  been  opened. 

The  operator  then,  after  feeling  for  the  prostate  and  localizing  the 
hypertrophies  to  be  removed,  introduces  a  strong  pair  of  scissors  and 
divides  the  organ  in  the  median  line  or  over  the  hypertrophy,  and 
rapidly  enucleates  the  mass  or  masses  with  his  finger. 

Bleeding  may  be  considerable,  but  may  usually  be  checked  with 
very  hot  water.  Perineal  urethrotomy  should  next  be  performed  for 
safety  and  drainage,  and  should  the  bleeding  be  sufficient  to  demand 
it,  the  bladder  may  then  be  packed  with  gauze.  Drainage  should  be 
established  through  both  wounds  with  large  rubber  tubes. 

Castration  for  HypertropMed  Prostate. 

Castration  for  enlarged  prostate  will  reduce  the  size  of  the  organ 
and  may  greatly  relieve  the  symptoms,  although  in  some  cases  its  effect 
seems  to  be  entirely  negative,  as  in  one  of  my  own  cases,  in  which  the 
organ  was  removed  six  weeks  after  the  operation  (death  being  due  to 
another  cause),  and  the  most  careful  microscopic  examination  failed 


OPERATTOISrS    ON   THE   MALE   GENITO-UKINAEY   ORGANS.  497 

to  detect  any  signs  of  atrophy  or  degeneration.  Ligation  of  tlie  vasa 
deferentia  in  the  cases  which  have  been  reported  seems  to  do  as 
well,  and  is  a  less  serious  operation,  besides  having  a  much  less  de- 
pressing mental  effect  upon  the  patient. 

Cancer  of  the  Prostate. 

Primary  cancer  of  the  prostate  is  rare.  More  usually  the  disease 
is  secondary  to  cancer  of  the  rectum  or  bladder,  and  due  to  direct 
extension,  or  to  metastasis.  It  occurs  chiefly  in  j^oung  children  and 
old  men. 

The  diagnosis  is  to  be  made  by  examination  of  the  enlarged  and 
stony  organ  through  the  rectum,  by  the  pain,  the  cachexia,  and  the 
enlarged  lymphatics  in  the  groin  and  Scarpa's  triangle. 

The  treatment  is  the  same  as  that  for  enlargement  of  the  prostate. 
Extirpation,  although  it  may  be  successful  as  far  as  the  immediate 
result  is  concerned,  holds  out  little  hope  of  any  lengthened  relief 
from  the  disease. 

Removal  of  the  Seminal  Vesicles. 

Chronic  inflammation  of  the  seminal  vesicles  is  a  condition  so  re- 
bellious to  treatment  and  so  serious  for  the  patient,  that  the  surgeon 
is  often  driven  to  adopt  any  treatment,  however  radical,  which  holds 
out  a  prospect  of  relief. 

Symptoms. 

These  are  often  very  obscure  and  chronic,  and  the  patient  will 
often  have  been  under  treatment  for  years  for  rectal,  bladder,  or  ure- 
thral disease.     They  consist  briefly  in  : 

Pain. 

Tenderness. 

Functional  disturbance. 

N'euroses. 

Urethral  discharge. 

Pain  is  both  local  and  reflex.     It  is  persistent,  and  subject  to  ex- 


498  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

acerbations  due  to  defecation,  urination,  or  sexual  excitement.  It 
may  be  referred  to  the  rectum,  the  neck  of  the  bladder,  glans  penis, 
pubes,  or  to  the  loins,  scrotum,  and  thighs.  The  tenderness  is  best 
appreciated  by  local  examination  with  the  finger  in  the  rectum, 
although  deep  pressure  in  the  perineum  or  over  the  pubes  will  easily 
elicit  it. 

Sexual  disturbance  may  be  of  every  kind.  Desire  may  be  mor- 
bidly increased,  but  in  chronic  cases  is  apt  to  be  almost  entirely 
absent. 

The  neuroses  are  also  of  almost  every  possible  kind.  The  patients 
are  generally  subject  to  great  mental  depression  and  wander  from 
one  surgeon  to  another,  willing  to  submit  to  any  operation  and  beg- 
ging for  relief.  They  will  consume  hours  in  describing  uneasy  and 
painful  sensations  in  every  part  of  the  pelvis  and  adjacent  parts. 
With  this  there  is  loss  of  flesh,  strength,  appetite,  and  sleep. 

Urethral  discharges  may  or  may  not  be  present,  and  are  rather  a 
symptom  of  the  acute  than  the  chronic  form  of  the  disease. 

Diagnosis. 

This  is  made  only  by  rectal  touch  and  by  discovering  with  the 
finger  a  tender,  hard  mass  behind  the  prostate  in  the  location  of  the 
vesicles. 

The  operation  is  difficult,  has  seldom  been  performed,  and  yet 
seems  to  hold  out  the  only  prospect  of  relief  in  old  cases.  Fuller 
has  done  it  twice,  Weir  once.  Gay  once  for  primary  cancer  of  the 
vesicle,  and  the  author  twice,  in  this  country,  and  there  are  a  few 
other  cases.  In  one  of  my  own  cases  I  was  fortunate  enough  to 
come  down  upon  a  nest  of  calculi,  varying  in  size  from  the  head  of  a 
pin  to  a  small  pea,  and  this  man  was  greatly  relieved. 

Before  operating,  a  sound  should  be  tied  into  the  bladder  for  a 
guide.  This  will  be  of  the  greatest  assistance — greater  than  distend- 
ing the  bladder  with  fluid. 

I  have  operated  both  by  a  transverse  incision  across  the  perineum, 
between  the  rectum  and  urethra,  and  by  a  median  posterior  incision, 
and  much  prefer  the  latter,  or  some  extension  of  it. 

The  perineal  incision  is  very  deep,  necessarily  funnel-shaped,  and 


OPERATIONS   ON   THE   MALE   GENITO-URINARY    ORGANS. 


499 


closed  at  the  bottom  by  the  prostate,  behind  which  are  the  vesicles 
still  to  be  reached. 

VanDittel's  incision,  as  shown  in  Fig.  266,  has  great  advantages  in 
giving  room,  and  is  the  one  to  be  preferred.  The  ordinary  Kraske, 
no  matter  how  long  above,  does  not  give  the  same  access  to  the 
parts  as  when  supplemented  by  a  curved  incision  around  one  side  of 
the  anus,  which  allows  the  anus  as  well  as  the  rectal  pouch  to  be 
turned  to  the  opposite  side  and  held  out  of  the  way.    The  removal 


Fig.  266. 
Van  Dittel's  Incision  for  Removal  of  the  Seminal  Vesicles. 


of  the  last  sacral  vertebra,  together  with  the  coccyx,  will  usually  give 
sufficient  room  above.  The  levator-ani  on  one  side  should  be  freely 
divided  and  the  operator  is  down  upon  the  prostate. 

The  difficulties  of  the  operation  really  begin  when  the  search  for 
the  vesicles  is  commenced  in  the  bottom  of  this  incision.  They  must 
not  be  expected  to  show  as  they  do  in  anatomical  drawings,  but  in 
any  case  in  which  their  removal  is  indicated,  they  will  generally  be 
so  concealed  in  a  mass  of  inflammatory  deposit  as  to  be  scarcely  rec- 
ognizable. 


500 


SURGERY    OF    THE    RECTUM    AND    PELVIS. 


It  is  this  plastic  deposit  at  wliicli  tlie  operator  must  work,  tear- 
ing it  away  witli  the  finger  or  sharp  curette,  and  removing  it  -in 
pieces  with  the  forceps,  till  finally  the  vesicles  are  liberated  and 
scraped  out. . 


Fm.  267. 
Zuckerkandl's  Incision  for  Removal  of  Seminal  Vesicles. 

P.,  prostate. 

V.  d.,  vas  deferens. 

V.  S.,  seminal  vesicle. 
B.,  bladder. 
M.,  rectum. 

The  peritoneum  should  not  be  opened,  and  if  opened  should  be 
sutured.  Wound  of  the  bladder  calls  for  free  drainage  of  the  in- 
cision. 

Operation  through  the  Rectum. 

Belfield  has  removed  the  seminal  vesicles  in  two  cases  by  the 
rectum.  In  one  of  these  cases  he  also  found  and  removed  two  small 
calculi. 

The  patient  is  laid  upon  the  affected  side,  the  sphincters  stretched, 
and  the  rectum  cleansed  and  plugged  high  up  with  iodoform  gauze. 


OPERATIONS    ON    THE   MALE   GENITO-UKINAKY    ORGANS.  501 

Witli  retractors  tlie  rectum  is  held  open  and  a  longitudinal  inci-" 
sion,  half  an  inch  long,  is  made  over  the  lower  end  of  the  distended 
vesicle.  The  vesicle  is  then  drawn  through  this  incision  with  an 
aneurism  needle  and  incised  or  excised  as  may  seem  necessary. 

The  operation  is  named  by  him,  spermato-cystotomy.     (Park.) 

Bupture  of  the  Bladder. 

This  may  be  due  to  external  violence,  or  internal  pressure  from 
distention,  but  much  more  frequently  from  the  former  than  the  latter. 

That  the  bladder  ma}^  occasionally  rupture  from  retention  of 
urine,  due  to  stricture  of  the  urethra,  is  a  fact  not  very  infrequently 
illustrated  in  our  hospitals.  Death  may,  however,  occur  from  con- 
gestion of  the  kidneys,  due  to  pressure  in  such  a  case,  before  the 
bladder-wall  gives  way. 

Rapture  from  external  violence  in  civil  practice  is  most  frequently 
caused  by  severe  falls  which  result  in  fracture  of  the  pelvis,  or  severe 
contusions  of  the  abdomen  occurring  when  the  bladder  is  full.  When 
the  bladder  is  empty  it  is  so  well  shielded  by  the  pelvic  bones  as  to 
be  safe  from  any  ordinary  contusion,  although  not  safe  from  w^ounds 
due  to  fracture  of  the  pelvis. 

In  military  service,  gun-shot  and  bayonet-wounds  of  the  bladder 
are  not  at  all  infrequent. 

Ruptures  of  the  bladder  divide  themselves  very  naturally  into 
intra-peritoneal  and  extra-peritoneal,  and  the  symptoms  and  physical 
signs  of  the  two  varieties  differ  very  markedly. 

Symptoms. 

The  history  is  of  great  importance.  In  rupture  from  over-disten- 
tion  caused  by  stricture,  this  will  be  that  of  long-continued  difRculty 
in  passing  water,  and  finally  of  total  inability  to  urinate,  and  also  of 
entire  loss  of  desire  to  do  so. 

In  other  cases  there  will  be  the  history  of  a  fall  or  injur}'-.  Fre- 
quent and  painful  micturition  may  be  complained  of,  with  the  passage 
of  only  a  few  drops  of  bloody  urine,  and  catheterization  will  reveal 


502  SURGERY    OF   THE    RECTUM    AND   PELVIS. 

an  empty  bladder.  There  may  be  an  external  wound  tlirougli  wliicli 
the  urine  escapes. 

In  cases  of  extra-peritoneal  rupture,  the  signs  of  urinary  infiltra- 
tion will  soon  show  themselves,  and  a  boggy,  (Edematous  reddish 
swelling  will  appear  either  above  the  symphysis,  or  in  the  perineum, 
or  scrotum. 

In  intra-peritoneal  rupture  there  may  be  no  local  symptoms,  but 
a  condition  of  collapse  with  empty  bladder. 

In  any  doubtful  case  the  bladder  should  at  once  be  tested  by  in- 
jecting a  saline  solution  through  a  catheter.  If  the  bladder  distends 
and  the  well-known  pear-shaped  tumor  appears  over  the  symphysis 
there  is  no  rupture.  If  a  measured  quantity  is  injected  and  only  a 
part  of  it  can  be  withdrawn,  the  diagnosis  is  clear. 

In  rare  cases  there  may  be  rupture  without  escape  of  urine.  The 
rent  may  be  valvular,  preventing  the  sudden  egress  of  any  large 
amount  of  urine,  or  it  may  be  plugged  by  a  loop  of  intestine  which  it 
grasps  firmly  ;  or  the  rupture  may  be  sub-peritoneal  and  only  partial, 
in  which  case  extravasation  may  be  very  slow,  and  all  symptoms  be 
masked  for  several  days. 

Treatment. 

This  depends  entirely  upon  whether  the  rupture  be  intra-  or  ex- 
tra-peritoneal, and  in  any  doubtful  case  an  exploratory  supra-pubic 
incision  should  be  made  to  decide  this  point.  When  the  space  of 
Retzius  has  been  opened  by  the  ordinary  incision  for  supra-pubic 
cystotomy,  most  extra-peritoneal  ruptures  will  be  apparent  by  the 
urinary  infiltration  ;  although  there  exists  a  class  of  cases  in  which 
extra-peritoneal  rupture  has  occurred  behind  the  prostate,  and  in 
which  the  infiltration,  though  extensive,  may  be  deep  in  the  pelvis. 

Should  the  rupture  prove  to  be  intra-peritoneal  the  abdominal 
cavity  is  opened  by  continuing  the  same  incision  upward. 

When  the  rent  in  the  bladder-wall  is  found,  its  treatment  must  in 
a  measure  depend  upon  its  character.  Should  it  be  clean-cut  and 
without  much  laceration  it  should  be  carefully  closed  by  interrupted 
sutures  of  fine  black  silk.  These  should  be  in  one  layer,  including 
the  peritoneal  and  muscular  coats,  and  should  be  so  carefully  applied 
that  no  leakage  is  possible. 


OPEEATIONS   ON   THE   MALE   GENITO-URINARY   ORGANS.  503 

On  the  other  hand,  should  the  edges  of  the  rent  be  ragged  and 
torn,  so  that  perfect  coaptation  is  difficult  or  impossible  without 
trimming  them  away  to  a  considerable  extent,  suture  may  be  aban- 
doned, the  abdomen  well  flushed  with  sterilized  water,  and  the  wound 
in  the  abdominal  wall  drained. 

In  any  case,  whether  the  wound  has  or  has  not  been  sutured, 
perineal  urethrotomy  and  drainage  will  add  greatly  to  the  safety  of 
the  patient. 

When  the  rupture  is  found  to  be  extra-peritoneal  it  may  be  either 
sutured,  or  drained,  or  stitched  to  the  abdominal  incision,  depending 
upon  its  character  and  extent.  Suture  will  be  found  diflScult  as  the 
bladder  tends  to  conceal  itself  behind  the  symphysis. 

Here  also  perineal  drainage  may  be  of  great  value,  and  the  supra- 
pubic skin  incision  should  be  drained  and  not  sutured,  even  though 
the  bladder  wound  may  have  been  closed. 

Extravasated  urine  may  require  special  treatment,  and  this  is  only 
by  free  incisions  to  relieve  all  tension.  A  very  long  incision  when 
the  scrotum  is  inflltrated  with  urine  and  enlarged  to  the  size  of  a 
child's  head  looks  very  much  smaller  the  next  day.  The  object  of 
the  incisions  being  to  allow  of  free  escape  of  urine  from  the  cellular 
tissue,  and  prevent  sloughing  by  relieving  tension,  they  should  also 
be  multiple. 

Vesical  Calculus. 

Stone  may  be  removed  from  the  bladder  by  supra-pubic  incision, 
by  perineal  incision,  or  by  a  combined  crushing  and  washing  opera- 
tion known  as  litllolapax3^ 

Into  the  relative  advantages  of  the  median,  lateral,  bilateral,  and 
medio-bilateral  incisions  in  the  perineum,  it  is  hardly  worth  while  at 
the  present  day  to  enter. 

The  median  incision  seems  to  have  all  the  advantages  that  are 
possessed  by  either  of  the  others,  and  any  stone  which  cannot 
be  removed  through  it  after  dilatation  of  the  neck  of  the  bladder 
with  the  finger,  without  lacerating  the  prostate,  should  be  crushed 
and  removed  in  fragments. 

The  incision  and  technique,  until  the  stone  is  reached,  is  the  same 


504  SURGERY   OF   THE    RECTUM   AND    PELVIS. 

as  in  external  nretLrotomy  witli  a  guide.  If  the  stone  be  large  a 
blunt-pointed  bistoury  may  be  passed  along  the  staff,  and  the  neck  of 
the  bladder  divided  slightly  in  a  downward  dii^ection  to  allow  of 
easier  escape  of  the  stone. 

When  the  stone  has  been  felt,  the  forceps  for  seizing  it  may  be 
passed  along  the  finger  as  a  guide  till  it  is  grasped,  or  the  finger  may 
be  removed  and  the  forceps  passed  without  it.  By  gentle  traction, 
combined  with  a  side-to- side  motion,  a  stone  of  considerable  size 
may  be  brought  through  the  neck  of  the  bladder  without  undue 
violence. 

In  the  lateral  operation  the  superficial  incision  begins  at  the  left 
of  the  raphe  and  extends  about  three  inches  downward  and  outward 
into  the  ischio-rectal  fossa.  The  neck  of  the  bladder  and  prostate 
also,  instead  of  being  divided  in  the  median  line,  are  incised  through 
the  left  lobe  of  the  prostate. 

In  the  bilateral  operation  the  incision  is  crescentic  across  the 
raphe  three-fourths  of  an  inch  in  front  of  the  anus,  and  extends 
downward  into  the  ischio-rectal  fossa  on  each  side.  After  the 
urethra  is  opened  a  double  bistoury  caclie  is  passed  into  the  bladder, 
turned  so  that  the  knives  will  cut  downward  and  outward,  set  to  the 
desired  size,  and  withdrawn,  making  an  incision  into  each  lateral 
lobe  of  the  prostate. 

After  removal  of  the  stone  by  any  of  these  incisions,  and  after 
careful  search  for  a  second  and  third  stone  till  the  operator  is  con- 
vinced that  the  bladder  is  empty,  the  bladder  should  be  thoroughly 
irrigated  with  hot  water  and  the  incision  dilated  with  dressing 
forceps  to  facilitate  the  escape  of  fragments.  A  drainage-tube 
of  rubber  may  then  be  employed  for  a  few  days,  although  this 
can  generally  be  dispensed  with,  with  increase  to  the  comfort  of 
the  patient. 

If  subsequent  washing  of  the  bladder  be  found  necessarj^  it  can 
be  done  very  easily  by  introducing  a  rubber  catheter  into  the  bladder 
through  the  incision  whenever  necessary. 

Supra-pubic  cystotomy  for  stone  differs  in  no  way  from  the  same 
operation  for  other  conditions,  and  the  reader  is  referred  to  the  de- 
scription of  that  operation. 


OPERATIONS    ON   THE    MALE    GENITO-UEINAKY    ORGANS. 


505 


Litholapaxy. 

For  tlie  performance  of  this  operation  special  instruments,  per- 
fected by  Bigelow,  are  essential.  They  consist  in  a  set  of  lithotrites 
for  first  crushing  the  stone,  and  in  a  powerful  and  very  perfect 
evacuator  for  removing  the  fragments  by  suction. 


Pig.  268. 
Bigelow's  Lithotrite. 


The  lithotrite  (Fig.  268)  is  passed  as  an  ordinary  sound  would 
be,  except  that  the  rule  to  let  it  find  its  own  way,  after  the  mem- 
branous urethra  has  been  reached,  is  to  be  strictly  enforced.  It  is  so 
heavy  that  it  can  be  safely  counted  upon  to  do  this.  When  the  in- 
strument is  in  the  bladder,  a  certain  method  should  be  followed  in 
trying  to  grasp  the  stone. 


506 


SURGERY    OF   THE    RECTUM    AND    PELVIS. 


The  blades  are  first  pressed  gently  onward  until  the  fundus  of  the 
bladder  is  reached,  and  while  the  female  blade  remains  at  this  point, 
the  male  blade  is  gently  withdrawn  as  far  as  the  neck  of  the  bladder 
and  closed  again  to  see  if  the  stone  has  fallen  into  the  grasp  of  the 
instrument,  as  it  generally  will. 

If  this  attempt  fails  it  should  be  repeated  in  the  same  way  with 
the  instrument  turned  first  to  the  right  and  then  to  the  left,  the 
female  blade  remaining  immovable  at  the  posterior  wall  of  the  blad- 


FiG.  269. 
Bigelow's  Evacuator. 


der,  and  the  male  being  gently  opened  and  closed.  Finally  the  beak 
may  be  turned  backward  and  an  attempt  made  to  grasp  the  stone 
behind  the  prostate. 

When  the  stone  is  felt  it  must  be  secured  before  any  attempt  is 
made  to  crush  it,  and  this  is  done  by  gently  but  firmly  closing  the 
instrument,  and  if  the  stone  does  not  escape,  locking  it  before  the 
crushing  force  is  applied  with  the  screw. 

The  operation  of  crushing  should  be  repeated  as  long  as  any  frag- 
ments can  be  grasped,  and  the  lithotrite  is  then  withdrawn  and  an 
evacuating  tube  substituted. 


OPEFwATIONS   OK  THE   MALE   GENITO-UKINARY    OEGANS.  507 

The  bulb,  filled  with  warm  sterilized  water,  is  then  connected  with 
the  tube  and  the  bladder  filled  with  fluid.  After  a  moment's  delay 
the  pressure  upon  the  bulb  is  relaxed,  the  water  returns,  carrying  the 
fragments  of  stone  with  it,  which  fall  into  the  glass  receiver,  and  this 
is  repeated  until  the  water  returns  clear  (Fig.  269). 

There  are  several  contra-indications  to  Bigelow's  operation. 

In  old  cases  of  stone,  attended  by  severe  chronic  cystitis,  no  pro- 
vision is  made  for  drainage  of  the  bladder. 

A  stricture  of  the  urethra  may  prevent  the  passage  of  the  instru- 
ments. 

The  stone  may  be  so  encysted  as  to  be  beyond  the  reach  of  the 
lithotrite. 

The  stone  may  be  known  to  have  a  nucleus  which,  on  account  of 
its  softness,  cannot  be  crushed,  as,  for  example,  a  broken  end  of  a 
catheter,  and  which  will  remain  in  spite  of  the  operation  to  form  a 
new  calculus. 

Enlargement  of  the  prostate  may  render  section  of  the  bladder 
absolutely  necessary. 

In  all  such  cases,  except  the  latter,  a  combined  operation  of  ex- 
ternal urethrotomy  with  lithotrity,  if  found  necessary  to  remove  the 
stone,  is  to  be  recommended.  Reginald  Harrison  has  experimented 
with  crushing  forceps,  which  are  powerful  enough  for  all  purposes, 
and  his  instruments  and  evacuating  tubes  require  no  more  room  than 
the  index  finger.     His  conclusions  in  favor  of  the  operation  are  : 

"It  enables  the  operator  to  crush  and  evacuate  large  stones  in  a 
short  space  of  time. 

"  It  is  attended  with  a  very  small  risk  of  life  as  compared  with 
other  operations  where  any  cutting  is  done,  such  as  lateral  or  supra- 
pubic lithotomy,  and  is  well  adapted  to  old  and  feeble  subjects. 

"  It  permits  the  operator  to  wash  out  the  bladder  and  any  pouches 
connected  with  it  more  effectually  than  by  the  urethra,  as  the  route 
is  shorter  and  the  evacuating  catheters  employed  of  much  larger 
calibre. 

"The  surgeon  can  usually  ascertain,  either  by  exploration  with 

the  finger  or  the  introduction  of  forceps  into  the  bladder,  that  the 

viscus  is  cleared  of  all  debris. 

"It  enables  the  surgeon  to  deal  with  certain  forms  of  prostatic 
32 


508  SUKGEEY    OF   TllK    KKCTUM    AND    PELVIS. 

outgrowth  complicated  wifli  atony  of  the  bladder  in  sucli  a  way  as 
to  secure  not  only  the  removal  of  the  stone,  but  the  restoration  of 
the  function  of  micturition. 

"By  the  subsequent  introduction  and  temporary  retention  of  a 
soft  rubber  drainage-tube,  states  of  cystitis  due  to  the  retention  of 
urine  in  pouches  and  depressions  in  the  bladder  wall  are  either  en- 
tirely cured  or  are  permanently  improved.  To  lock  up  unhealthy 
ammoniacal  urine  in  a  bladder  that  cannot  properly  empty  itself 
after  a  lithotrity  is  to  court  the  formation  or  recurrence  of  a  phos- 
phatic  stone.  Hence  it  is  well  suited  to  some  cases  of  recurrent  cal- 
culus. 

"It  is  well  adapted  for  some  cases  of  stone  in  the  bladder,  com- 
plicated with  stricture  of  the  deep  urethra,  as  it  enables  the  surgeon 
to  deal  with  both  at  the  same  time.  Nor  does  it  expose  the  patient 
to  the  risk  which  may  be  attendant  where  lithotrity  is  performed  with 
a  weakened  or  permanently  damaged  urethra." 

Siupra-puhic  Cystotomy. 

The  bladder,  in  its  undistended  state,  lies  well  behind  the  pubes 
and  cannot  be  reached  from  above  without  cutting  through  the  peri- 
toneum. When,  however,  the  organ  is  moderately  distended  it  rises 
above  the  symphysis,  carrying  the  peritoneum  with  it  and  an  inci- 
sion through  the  abdominal  wall  may  easily  reach  its  upper  portion 
without  opening  the  peritoneum. 

The  prevesical  space  of  Retzius  is  shown  in  Fig.  270,  and  before 
the  operation  this  must  be  increased  as  much  as  possible  by  inject- 
ing the  bladder. 

A  soft  catheter  is  therefore  passed  whenever  possible,  and  after 
the  urine  is  drawn  the  bladder  is  distended  with  saline  solution  till  it 
can  be  distinctly  marked  out  by  percussion  above  the  symphysis. 

A  good  syringe  for  this  purpose  is  shown  in  Fig.  271. 

Another  method  of  raising  the  bladder  is  by  distending  the  rec- 
tum. Both  methods  are  not  necessary,  but  in  any  cnse  in  which, 
owing  to  the  presence  of  a  stricture,  a  catheter  cannot  be  passed  for 
injection,  the  bladder  should  be  raised  by  this  means.  A  soft  rubber 
bag,  known  as  a  rectal  colpeurynter,  is  passed  empty  into  the  rectal 


OPERATIONS    ON   THE   MALE   GENITO-UlilNAKY    ORGANS.  509 


Fig.  270. 

Section  of  Pelvis. 

Space  of  Retzius,  shaded  in  front, 
t  Post-rectal  Connective  Tissue. 


610  SURGERY    OF   THE    KECTUM   AND    PELVIS. 

pouch  above  the  sphincter,  and  then  distended  by  injecting  water. 
Twelve  ounces  of  water  in  the  rectum  and  the  same  amount  in  the 
bladder  mark  the  limit  of  safety. 

When  the  bladder  has  been  filled  the  penis  is  grasped  tightly  be- 
tween the  thumb  and  finger,  the  catheter  withdrawn  and  a  tape  tied 
around  the  organ  tightly  enough  to  keep  the  fluid  from  escaping. 

With  the  patient  in  the  Trendelenberg  posture,  a  median  incision, 
three  inches  long,  is  made  with  its  lower  end  as  near  the  symphysis 
as  possible.  This  incision  is  carried  between  the  recti  muscles  in  the 
usual  way  in  opening  the  abdomen. 

By  a  gentle  separation  of  the  lips  of  the  incision,  the  index  finger 


Fig.  271. 
Sjringe  for  Injecting  the  Bladder. 

is  carried  down  to  the  bladder  as  close  to  the  symphysis  as  pos- 
sible, and  the  prevesical  fat  is  pushed  upward  so  as  to  clear  the 
surface  of  the  bladder. 

Not  infrequently  the  lower  reflected  border  of  the  peritoneum 
can  be  plainly  seen  as  it  passes  from  the  bladder  to  the  abdominal 
wall,  and  this  may  also  be  pushed  upward  out  of  the  way  of  the 
incision  to  be  made  into  the  bladder. 

With  a  medium-sized  Hagedorn  needle,  two  loops  of  catgut  are 
next  carried  through  the  wall  of  the  bladder,  one  on  each  side  of  the 
point  at  which  the  incision  is  to  be  made,  and  intrusted  to  an  assist- 
ant to  hold  the  cut  edges  of  the  incision  after  the  bladder  has  been 
opened.  It  is  well  to  select  for  the  incision  a  part  which  is  not 
crossed  by  any  large  vein.  A  straight  bistoury  is  next  passed  into 
the  bladder  between  the  two  guiding  loops  and  the  incision  enlarged 
to  the  extent  of  an  inch. 


OPERATIONS    ON   THE   MALE   GENITO-URINAKY   ORGANS.  511 

The  operation  may  be  done  in  two  stages,  as  recommended  by 
Senn. 

In  any  case  of  old  cystitis  there  is  liability,  if  the  operation  is  per- 
formed as  described  above,  of  setting  up  an  inflammation  of  the  pre- 
vesical pelvic  tissue  from  the  escape  of  foul  urine.  This  will  not 
only  prevent  healing  but  may  reach  an  extent  dangerous  to  life. 

To  avoid  this  complication,  Senn  proposes,  after  the  site  of  the 
incision  into  the  bladder  has  been  exposed,  to  pack  the  wound  with 
iodoform  gauze,  cover  it  with  an  external  dressing,  and  leave  it  for 
about  five  days,  until  the  cellular  plains  have  become  closed  by 
granulation.  The  incision  into  the  bladder  can  then  be  made  with 
cocaine. 

Having  opened  the  bladder  the  subsequent  treatment  of  the 
wound  must  depend  upon  its  condition. 

Where  the  operation  has  been  done  for  stone  or  tumor,  and  there 
is  no  cystitis,  and  no  danger  of  hemorrhage,  the  wound  may  be 
closed  by  Lembert's  sutures.  These  should  be  accurately  applied, 
and  it  is  well  to  test  the  seam  by  again  moderately  distending  the 
organ  by  injection. 

In  all  other  cases  the  sides  of  the  bladder  incision  should  be 
stitched  to  the  abdominal  fascia  with  a  few  sutures  to  close  as  far  as 
possible  the  prevesical  space,  and  prevent  not  only  the  slipping 
away  of  the  organ,  but  the  infiltration  of  urine. 

The  most  efficient  drainage  can  be  secured  by  a  large  rubber  tube 
stitched  by  a  safety-pin  to  the  margin  of  the  wound.  The  tube  is 
removed  when  the  urine  becomes  clear. 

In  cases  of  profuse  hemorrhage,  as  in  operations  for  the  removal  of 
tumors,  or  of  pieces  of  hypertrophied  prostate,  where  hot  irrigation 
fails  to  check  the  bleeding,  the  whole  bladder  may  be  safely  packed 
for  a  time  with  sterilized  (not  iodoform)  gauze  ;  and  a  perineal  sec- 
tion may  with  advantage  sometimes  be  added  to  the  supra-pubic  in- 
cision for  drainage. 

Irrigation  of  the  Bladder. 

The  instruments  necessary  are  a  soft-rubber  catheter  and  the  sy- 
ringe shown  in  Fig.  271. 


512 


SURGERY    OF   THE   RECTUM   AND   PELVIS. 


When  performed  by  the  patient  himself  the  fountain  syringe, 
with  two-way  stopcock,  shown  in  Fig.  272,  will  be  more  convenient 
and  safer. 

Tlie  temperature  of  the  fluid  as  it  enters  the  bladder  should  be 
that  of  the  body.  When  the  fountain  syringe  is  used  it  should  be 
slightly  warmer,  to  allow  for  cooling.  When  the  bladder  is  full  the 
stop-cock  is  turned  and  the  fluid  evacuated.  The  irrigation  should 
be  repeated  till  the  returned  fluid  is  clear. 

The  great  danger  of  this  simple  surgical  procedure  is  the  setting 
up  of  a  cystitis  which  ma}^  be  extremely  serious. 


Pig.  272. 
Apparatus  for  Irrigating  the  Bladder. 


To  avoid  this  the  most  careful  antisepsis  should  constantly  be 
practised.  The  catheter  should  be  boiled  before  using,  and  should 
be  kept  in  a  solution  of  bichloride,  1  to  2,500,  when  not  in  use. 

The  syringe  and  all  tubing,  no  matter  what  form  of  instrument  is 
used,  should  be  sterilized  by  boiling  each  time  they  are  used. 

Sterilized  olive  oil  should  be  used  as  a  lubricant. 

The  meatus  and  glans  should  be  washed  in  1  to  2,500  bichloride 


OPERATIONS    ON   THE   MALE   GENITO-URINARY   ORGANS.  513 

before  the  catheter  is  inserted ;  and  as  it  is  slowly  carried  onward 
into  the  bladder  a  steady  stream  of  1  to  5,000  bichloride  should  be 
kept  up  to  flush  the  urethra. 

Every  surgeon  has  his  own  preference  for  solutions  to  be  used  in 
washing  out  the  bladder.  Perhaps  nothing  is  better,  in  case  cystitis 
does  not  already  exist,  as  in  cases  of  commencing  catheterism  for 
prostatic  enlargement,  than  simple  saline  solution,  a  tablespoonful 
to  the  quart.  When  cystitis  actually  exists,  there  are  many  formulse 
which  have  been  found  serviceable  in  overcoming  it.  Nitrate  of  sil- 
ver, 1  to  1,000,  and  bichloride  of  mercury,  1  to  10,000,  to  be  followed 
by  simple  saline,  are  both  favorites.  A  solution  of  salicylic  acid  is 
easily  prepared,  and  is  vevj  efiicienL     The  formula  is  : 

Salicylic  acid  grs.  viii. 

Alcohol §  i. 

One  ounce  of  this  solution  added  to  a  pint  of  hot  water  gives  a  solu- 
tion of  one-half  a  grain  to  the  ounce,  which  is  ready  for  use. 
Thiersch' s  solution  is  : 

Salicylic  acid 3  ss. 

Pulv.  boric  acid 3  iii.  ss. 

Hot  water 1  quart. 

This  may  be  used  in  full  strength  or,  as  is  more  usual  in  mild  cases, 
diluted  one-half. 

If  astringents  are  preferred,  acetate  of  lead  (half  a  grain  to  the 
ounce),  sulphate  of  zinc  (one  grain  to  the  ounce),  and  nitrate  of  sil- 
ver (grains  1  to  10  to  the  ounce),  are  all  reliable  and  not  too  strong 
to  be  safe. 

Genito-  Urinary  Tuberculosis. 

Tubercular  inflection  of  the  prostate  and  bladder  is  generally 
associated  with  the  same  process  in  the  epididymis  or  kidney,  or 
both,  and  is  perhaps  usually  derived  from  some  distant  organ,  as  the 
lungs  or  cervical  glands.  As  in  all  infections  of  the  genito-urinary 
organs  the  soil  must  first  be  prepared  for  the  bacillus,  and  this  is 
usually  done  by  a  pre-existing  cystitis. 


514  SURGEEY   OF   THE   EECTUM   AXD   PELVIS. 

Direct  inoculation  from  one  tubercular  patient  to  anotlitr  in 
coition  is  onlj-  a  supposition  lacking  evidence.  Direct  inoculation 
from  the  kidnej^  to  the  bladder  is  more  than  probable. 

The  symptoms  are  those  of  a  chronic  cystitis  associated  with  tu- 
mor in  the  epididymis,  prostate,  or  kidney. 

The  diagnosis  may  for  a  long  time  be  doubtful  unless  the  swell- 
ings appear  or  the  bacillus  be  examined  for  in  the  urine. 

Pain  is  usually  an  early  symptom,  and  may  be  very  constant  and 
severe.  Pus  in  the  urine  is  a  result  of  the  cystitis,  and  is  a  late 
rather  than  an  early  symptom.  Ulceration  shows  itself  by  an  in- 
crease in  intensity  of  all  the  symptoms  and  occasionally  by  hemor- 
rhage. The  ulceration  may  go  on  to  destruction  of  the  neck  of  the 
bladder  and  incontinence  of  urine. 

Treatment. 

The  only  surgical  treatment  possible  in  tuberculosis  of  the  pros- 
tate or  bladder  is  supra-pubic  cystotomy  for  the  relief  of  symptoms. 
All  other  treatment  is  purely  general. 

In  tuberculosis  of  the  epididymis  or  of  the  kidney,  however,  be- 
fore the  bladder  or  prostate  show  any  signs  of  infection,  the  propri- 
ety of  castration  and  nephrectomy  on  the  side  affected  should  be 
seriously  considered.  It  is  possible  that  either  an  ascending  or  a  de- 
scending infection  may  be  prevented  by  this  means. 

.  Exstrophy  of  the  Bladder. 

Congenital  absence  of  the  anterior  abdominal  wall  and  anterior 
wall  of  the  bladder  is  generally  associated  with  separation  of  the 
pubic  bones  at  the  symphysis,  and  with  epispadias  involving  the 
deep  urethra. 

Although  the  condition  is  not  absolutely  incompatible  with  con- 
siderable length  of  life,  the  condition  of  the  patient  is  very  miserable. 
The  posterior  wall  of  the  bladder,  which  bulges  into  the  gap  left  in 
the  abdominal  wall,  becomes  excoriated,  the  urine  becomes  ammoni- 
acal,  and  no  urinal  or  apparatus  has  as  yet  been  found  which  will 
prevent  constant  escape  of  urine. 


OPERATIONS   ON   THE   MALE   GENITO-UKINARY   ORGANS.  515 

The  cure  is  only  by  some  sort  of  plastic  operation,  and  every 
surgeon  may  exercise  liis  ingenuity  in  this  regard.  Many  have  been 
reported,  some  in  their  different  stages,  extending  over  many  years, 
but  the  most  that  has  ever  been  accomplished  is  to  force  the  urine 
out  of  some  one  small  abnormal  opening,  so  that  it  could  be  collected 
by  a  urinal  instead  of  leaking  all  over  the  parts. 

Wood's  operation,  which  is  the  simplest  of  the  many  which  have 
been  practised,  also  gives  the  best  results.  By  it,  three  flaps  are 
made,  one  from  above,  and  one  from  each  side,  and  turned  down  and 
over  to  cover  the  gap. 

The  upper  flap  is  oblong  and  made  of  the  skin  of  the  abdomen  as 
far  up  as  the  umbilicus.  It  is  left  attached  by  a  broad  base  at  the 
upper  margin  of  the  deformity  and  turned  over  without  twisting,  so 
that  the  skin  surface  furnishes  an  anterior  wall  for  the  bladder.  A 
raw  surface  is  prepared  at  the  pubes  for  its  attachment,  and  to  this  it 
is  sutured. 

The  raw  surface  of  this  flap  is  next  covered  by  two  lateral  skin- 
flaps,  one  from  each  inguinal  region,  which  are  twisted  on  their 
attached  border  and  brought  together  in  the  median  line,  skin  surface 
upwards.  The  raw  surfaces  left  by  dissecting  up  the  flaps  are 
closed  as  far  as  possible  by  sutures. 

Persistent  UracJius. 

A  congenital  urinary  fistula  at  the  umbilicus  means  an  unclosed 
urachus. 

The  condition  is  generally  curable  by  perineal  cj^stotomy  in  the 
male  or  dilatation  of  the  urethra  in  the  female  to  prevent  the  bladder 
becoming  filled.  Combined  with  these,  cauterization  of  the  umbili- 
cal opening  should  be  tried. 

In  case  of  failure  of  these  methods,  the  abdomen  may  be  opened 
and  the  vesical  entrance  to  the  urachus  closed  by  sutures  after  being 
freshened. 

NepTirorrTiaphy. 

The  indication  for  fixation  of  the  kidney  by  sutures  is  not  alone 
its  mobility,  but  the  fact  that  its  mobility  is  a  cause  of  symptoms. 


516  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

It  is  unquestionable  that  a  kidney  may  be  freely  movable  with- 
out causing  the  least  disturbance,  intestinal,  nervous,  or  otlierwise, 
to  the  bearer. 

On  the  other  hand,  intense  pain  may  be  caused  by  obstruction  of 
the  ureter  from  malposition  of  the  kidney,  and  more  common  symp- 
toms are  obscure  paroxysmal  pain  in  the  lumbar  region,  dyspepsia, 
intestinal  catarrh,  dilatation  of  the  stomach,  and  neuroses  of  various 
kinds. 

The  incision  for  nephrorrhaphy  is  shown  in  Fig.  273. 

Usually  an  incision  from  the  last  rib  to  the  crest  of  the  ileum 
will  be  enough  for  a  skilful  operator,  but  should  it  be  necessary,  this 
may  easily  and  safely  be  prolonged  to  any  required  degree  by  ex- 
tending it  along  the  crest  of  the  ileum,  as  shown  by  the  dotted  line. 

The  patient  should  lie  on  the  abdomen,  or  with  the  affected  side 
slightly  raised  from  the  table,  with  a  hard  sand-bag  or  a  rubber 
cushion  under  the  loin  to  bring  the  site  of  the  incision  as  promi- 
nently into  view  as  possible. 

The  cushion  most  be  .small  enough  to  lie  between  the  thorax  and 
the  pelvis,  so  that  the  patient  is  sharply  bent  over  it  and  the  press- 
ure it  exerts  is  directly  upon  the  soft  parts.  By  this  means,  the 
kidney  to  be  operated  upon  is  most  completely  forced  upward  to  the 
skin  incision. 

The  incision  should  begin  at  the  lower  border  of  the  last  rib,  just 
outside  of  the  tip  of  the  transverse  process  of  the  first  lumbar 
vertebra,  and  extend  downward  and  slightly  outward  to  the  crest  of 
the  ileum.  In  this  way  it  will  reach  the  outer  border  of  the  erector- 
spinse  muscle,  which  is  the  point  desired. 

The  full  length  of  the  skin  incision  must  be  maintained  as  the 
deep  muscles  are  divided,  and  the  incision  must  be  carried  vertically 
downward  till  the  kidney  is  reached,  for  if  it  be  shortened  as  the  depth 
increases,  it  will  be  too  short  to  work  in  when  the  kidney  is  reached  ; 
and  if  it  be  bevelled  outward  the  peritoneum  will  be  opened. 

When  the  fatty  capsule  has  been  reached,  and  the  kidney  ex- 
posed, it  should  be  gently  brought  outside  of  the  body  through  this 
incision. 

At  this  point,  perhaps,  the  experience  of  the  operator  will  be 
most   manifest,   for  a  very  large  kidney  may  be   brought  outside 


OPEEATIONS    ON   THE   MALE   GENITO-URINARY   ORGANS.  517 


Fig.  273. 
Incision  for  Nephrorrhaphy. 


518  SURGEEY    OF   THE    RECTUM    AND    PELVIS. 

the  body  through  this  incision  without  laceration  or  rupture  by 
gentle  traction,  and  in  cases  of  nephrorrhaphy  it  will  very  rarely  be 
necessary  to  extend  the  incision  along  the  crest  of  the  ileum. 
Should,  however,  the  organ  prove  to  be  much  enlarged  or  distended 
with  pus,  it  is  better  to  lengthen  the  incision  than  rupture  it. 

The  kidney  should  be  separated  from  its  fatty  capsule  by  dis- 
section with  the  linger  before  any  attempt  to  bring  it  through  the 
incision  is  made,  and  it  should  be  tilted  so  that  one  end  is  first 
delivered  and  then  the  other. 

With  the  organ  grasped  firmly  in  the  fingers,  great  assistance 
may  be  given  by  making  traction  upon  the  feet  of  the  patient,  while 
the  shoulders  are  held  immovable.  In  this  way  the  incision  is  de- 
cidedly lengthened.  The  greatest  assistance  of  all,  however,  will 
come  from  having  the  incision  reach  from  rib  above  to  pelvis  below 
in  its  deeper  parts. 

After  bringing  the  kidney  out  of  the  incision,  the  next  step  is  to 
incise  the  fibrous  capsule  longitudinally  over  the  convexity  of  the 
organ  nearly  from  end  to  end,  and  with  the  handle  of  the  knife  dis- 
sect it  free  from  the  kidney  tissue  and  turn  it  back  for  nearly  an 
inch,  leaving  the  kidney  tissue  exposed  for  a  space  at  least  three 
inches  long  and  an  inch  and  a  half  wide  on  the  convexity. 

Three  suspensory  sutures  of  chroraicized  catgut  should  next  be 
passed  through  the  kidney  at  equal  distances  from  each  other,  in 
order,  when  the  kidney  has  been  replaced,  to  bring  its  denuded 
surface  up  into  contact  with  the  muscles  of  the  loin  and  hold  it  there. 

These  sutures  are  passed  completely  through  the  kidney  from 
side  to  side,  and  to  prevent  their  tearing  out  should  include  the  two 
layers  of  the  reflected  fibrous  capsule  on  each  side  of  the  dorsal  in- 
cision. The  reflected  capsule  thus  acts  in  giving  additional  sup- 
port to  the  suspensory  sutures,  and  is,  in  addition,  pinned  back  so 
that  it  cannot  prevent  the  contact  of  the  denuded  kidney  tissue  with 
the  muscles,  and  thus  prevent  union  of  the  two.     (Edebohls.) 

When  the  three  suspensory  sutures  have  been  passed  and  the  ends 
secured  with  six  forceps,  which  are  dropped  out  of  the  way  on  each 
side,  the  kidney  is  replaced  by  an  inverse  process  to  that  used  in 
bringing  it  out  of  the  body,  and  the  wound  is  closed. 

First  the  superfluous  fat  of  the  fatty  capsule  should  be  removed 


OPERATIONS    ON   THE   MALE    GENITO-URINARY    ORGANS.  519 

SO  that  it  may  not  prevent  union  of  the  incision,  and  of  tlie  kidney 
to  the  incision. 

Next  tlie  three  suspensory  sutures  are  to  be  brouglit  tlirough  the 
muscular  lips  of  the  incision  on  eacli  side  by  tlireading  eacli  end  to  a 
needle,  which  passes  through  the  muscular  tissue  from  within  to- 
ward the  skin. 

These  sutures  are  to  remain  buried  after  the  skin  wound  is  closed, 
and  after  the  ends  have  thus  been  passed  through  the  muscle  on  each 
side  of  the  incision,  they  are  again  marked  by  forceps  and  dropped 
out  of  the  way. 

Next  close  the  muscular  layers  of  the  incision  with  catgut,  after 
having  inserted  a  silk-worm  gut  drain  between  the  raw  surface  of 
the  kidney  and  the  muscles. 

Then  tie  the  suspensory  sutures,  making  gentle  traction  upon  each 
to  see  that  the  kidney  is  brought  firmly  against  the  muscles,  but 
taking  care  not  to  use  sufficient  force  to  tear  out  the  sutures. 

Finally  close  the  skin  incision,  and  dress  the  wound  with  gauze 
after  pressing  out  all  air  and  fluids.  The  drain  may  be  removed  at 
the  first  change  in  the  dressings  at  the  end  of  three  or  four  days. 

Should  the  peritoneum  be  opened  by  accident  in  this  operation  it 
should  be  sutured.  A  wound  of  the  pleura  will  be  marked  by  the 
sound  of  the  rush  of  air,  and  by  the  immediate  effect  upon  the  res- 
piration, and  this  also  should,  at  once,  be  sutured.  Rupture  of  the 
kidney  need  not  occur  to  a  skilful  operator.  - 

A  wound  of  the  pleura  is  said  to  have  been  immediately  fatal, 
but  in  the  only  case  in  which  I  have  seen  it  occur  the  effect  was 
rather  surprisingly  slight. 

Albumen  and  blood  in  slight  quantities  will  usually  be  noticeable 
in  the  urine  for  a  few  days  after  the  operation. 

Nephrotomy. 

With  the  kidney  exposed  and  drawn  out  of  the  body,  as  de- 
scribed, its  exploration  becomes  easy. 

Incision  into  the  kidney  substance  is  usually  done  to  facilitate 
the  exploration  for  calculus,  and  the  incision  may  be  made  either  on 
one  side  of  the  organ  near  the  pelvis,  or  on  the  convex  border,  or 


520  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

through  the  pelvis  proper.  The  incision  should  be  large  enough  to 
admit  the  index  finger  to  the  pelvis. 

Both  metal  sound  and  finger  may  be  used  for  exploration  of  the 
pelvis  and  mouth  of  the  ureter,  but  both  M'ith  gentleness,  as  the  pel- 
vis may  easily  be  punctured  with  a  sound. 

When  a  stone  is  found  it  is  to  be  gently  withdrawn  with  dressing- 
forceps,  and  the  incision,  if  in  the  pelvis,  may  be  sutured.  If  in  the 
cortex  it  should  be  left  to  close  without  suturing.  The  hemorrhage 
will  generally  cease  spontaneously  when  the  kidney  is  replaced  in 
its  bed.  A  urinary  fistula  will,  however,  remain  when  the  incision 
has  been  made  in  the  kidney  substance  until  the  wound  has  closed, 
and  on  this  account  the  external  wound  must  be  drained  and  left 
open. 

Such  a  fistula  may  be  permanent,  and  in  the  end  call  for  extirpa- 
tion of  the  organ. 

Renal  Calculus. 

The  diagnosis  of  renal  calculus  is  by  no  means  always  an  easy 
matter.  It  is  usually  made  from  the  attacks  of  pain,  and  the  pres- 
ence of  blood  and  pus  in  the  urine,  and  anything  which  causes  severe 
pain  in  the  region  of  one  kidney  is  liable  to  be  mistaken  for  stone. 

Perhaps  the  most  frequent  cause  of  error  will  be  found  in  pyelitis 
arising  from  any  other  cause  than  the  presence  of  a  calculus.  The 
symptoms  will  be  pain,  with  pus,  and  perhaps  blood,  in  the  urine — 
exactly  those  of  calculus. 

Neuralgia  of  the  kidney  may  exist  without  physical  changes  in 
the  organ,  and  the  paroxysmal  pain  may  strongly  resemble  that  of 
stone  ;  but  the  urine  will  be  clear  unless  there  be  cystitis. 

Pain,  with  slight  cystitis,  and  without  enlargement  of  the  kidney, 
form  a  most  perplexing  combination,  and  if  the  pain  be  severe 
enough  so  that  the  patient  demands  it,  they  justify  an  exploratory 
incision  through  the  loin. 

Another  condition  Justifying  exploration  for  stone  is  malignant 
disease  of  the  organ.  The  symptoms  may  be  indistinguishable  from 
those  of  calculus,  and  the  same  may  be  said  of  tuberculosis  of  the 
kidney. 

White  calls  attention  to  the  point  in  differential  diagnosis  that 


OPERATIOlSrS   ON   THE   MALE   GENITO-URINAEY    ORGANS.  621 

the  bleeding  in  calciihis  is  seldom  severe  ;  in  malignant  disease  it  is 
apt  to  be  much  more  severe  ;  while  in  tuberculosis  there  is  likely  to 
be  much  more  pus  than  blood. 

In  exploring  for  stone  it  should  not  be  forgotten  that  a  calculus 
may  exist  in  the  kidney  substance  which  cannot  be  reached  by  ex- 
ploration of  the  pelvis.  The  whole  substance  of  the  kidney  when 
out  of  the  body  in  this  operation  should  therefore  be  carefully  pal- 
.  pated  for  any  point  of  increased  hardness. 

Should  the  condition  of  the  corresponding  ureter  be  suspected,  it 
has  been  suggested  that  it  may  be  injected  from  the  pelvis  with  some 
colored  fluid,  or  with  milk,  and  the  bladder  then  catheterized  to  test 
its  permeability. 

Nephrectomy. 

The  most  frequent  indications  for  the  removal  of  a  kidney  are : 

Tumor. 

Movable  kidney  which  cannot  be  held  by  nephrorrhaphy. 

Urinary  fistula. 

Wounds  of  the  kidney. 

Wounds  of  the  ureter. 

Pyelitis. 

Pyelonephritis. 

Hydronephrosis. 

Perineplmtic  abscess. 

Before  removing  one  kidney  the  presence  and  condition  of  the 
other  must  be  determined. 

This  may  be  done  by  catheterization  of  the  opposite  ureter  as  de- 
scribed under  the  surgery  of  the  ureter  ;  but  very  few  men  are  able 
to  accomplish  this  feat  in  the  male  subject,  and  generally  the  only 
way  to  assure  one's  self  on  this  point  is  by  direct  examination  with 
the  hand  in  the  abdomen. 

Although,  therefore,  a  ver}^  large  kidney  may  be  removed  through 
the  lumbar  incision,  this  incision  will,  in  most  cases,  be  betteradapted 
for  nephrotomy  and  for  cases  of  urinary  fistulse,  and  an  anterior 
transperitoneal  incision  will  be  safer  for  extirpation  in  cases  of  tumor 
and  suppurative  disease. 


522  SURGERY    OF   THE   RECTUM    AND    PELVIS. 

Tills  should  be  made  either  in  the  linea  semilunaris,  or  over  the 
tumor. 

As  soon  as  the  condition  of  the  opposite  organ  is  found  to  justify 
the  completion  of  the  operation  the  intestines  are  drawn  to  one  side 
and  the  peritoneum  over  the  kidney  to  be  removed  is  incised. 

If  the  organ  be  found  in  the  condition  of  a  mere  pus-sac,  the  free 
edge  of  the  incision  into  the  peritoneum  of  the  mesocolon  may  be 
stitched  to  the  edge  of  the  parietal  peritoneum  and  the  general  peri- 
toneal cavity  thus  closed  off. 

In  pus  cases,  moreover,  it  is  justifiable  to  abandon  the  anterior 
exploratory  incision  after  being  satisfied  with  the  condition  of  the 
opposite  kidney,  and  proceed  with  the  extirpation  through  a  new 
lumbar  incision. 

An  incision  may  easily  be  made  parallel  with  the  free  margin  of 
the  ribs  and  well  back  in  the  loin  which  shall  combine  these  two  in- 
cisions. In  its  first  part  it  opens  the  peritoneum  and  allows  access 
to  the  other  kidney.  This  being  satisfactory,  the  peritoneal  cavity  is 
closed  by  suture,  and  the  incision  continued  backward  into  the  loin 
till  the  kidney  is  reached  behind  the  peritoneum. 

In  ligaturing  the  vessels  entering  the  pelvis  of  the  organ,  the  rule 
is  to  tie  the  blood-vessels  and  the  ureter  separately,  as  far  away  from 
the  kidney  as  possible.  When  room  can  be  obtained  for  a  double 
ligature  and  division  of  the  ureter  betw^een  the  two,  this  should  be 
adopted  to  prevent  soiling  the  wound  wdth  urine  or  pus  when  the 
ureter  is  cut. 

When  the  kidney  has  been  removed  by  a  transperitoneal  incision, 
the  cut  edges  of  the  mesocolon,  if  not  already  stitched  to  the  parietal 
peritoneum,  should  be  united  by  suturing,  after  the  wound  has  been 
drained  posteriorly  through  a  puncture  made  in  the  loin. 

Whether  drainage  should  or  should  not  be  employed  must,  as  in 
all  other  cases,  depend  upon  whether  the  wound  has  been  kept  asep- 
tic, or  not. 

After  nephrectomy  the  condition  of  the  other  kidney  may  be  a 
source  of  danger,  even  although  it  seemed  to  be  in  good  condition 
before  the  operation.  On  this  point  Meyer  says  :  "  There  evidently 
occurs  an  excessive  hyperjemia  in  the  remaining  kidney  immediately 
after  nephrectomy.     Its  presence   is   demonstrated   by  the   sudden 


OPERATIONS    ON   THE   MALE   GENITO-ITRINARY   ORGANS.  523 

change  in  the  transparency^  of  the  urine  if  the  remaining  kidney  had 
already  been  slightly  affected. 

"It  has  been  observed  by  many  who  have  done  several  nephrot- 
omies that  in  a  number  of  cases,  immediately  after  the  one  unhealthy 
kidney  has  been  removed,  the  urine  which  descends  from  its  probabl}^ 
onlj^  slightly  affected  fellow,  and  which  has  formerly  been  found 
comparatively  clear  with  the  help  of  cystoscopy,  or  after  nephrotomy 
on  the  other  side  had  been  done,  suddenly  becomes  very  turbid  and 
presents  an  unusually  heavy  deposit  after  short  standing.  As  I  have 
seen,  it  may  take  weeks  or  months  before  this  turbidity  lessens,  or 
disappears.  In  the  majority  of  cases  it  does  so,  however,  but  slowly 
and  gradually." 

His  suggestions  for  the  treatment  of  this  condition  are  as  follows  : 

"1.  Before  nephrectomy,  cystoscopy  should,  if  possible,  be  per- 
formed to  prove  the  presence  of  an  active  opposite  kidney. 

"  2.  This  will  be  generally  unnecessary  if  a  renal  fistula  exists  on 
the  diseased  side,  and  the  urine,  voided  jper  urethram^  is  clear  and 
sufficient  in  quantity.  But  even  in  these  cases  cystoscopy  will  be  a 
desirable  procedure  for  making  a  more  definite  prognosis. 

"If  the  cystoscope  has  demonstrated  the  presence  of  an  active 
opposite  kidney,  and  if  then  absolute  anuria  suddenly  sets  in  some 
time  after  nephrectomy  and  a  period  of  uninterrupted  recovery,  with 
the  secretion  of  a  satisfactory  amount  of  urine,  the  cause  must  be  a 
mechanical  one.  Nephrotomy  on  the  remaining  side  is  then  indi- 
cated as  the  only  means  to  save  the  patient' s  life. 

"  3.  Immediately  after  nephrectomy  there  is,  in  all  probability,  an 
acute  hypersemia  of  the  opposite  kidney.  This  hyperaemia  also  fre- 
quently occurs  in  the  female  sex,  especially  in  the  left  kidney,  at  the 
time  of  the  menstrual  period,  but  probably  to  a  much  less  extent. 

"4.  Such  hypersemia  may  suddenly  increase  an  incipient  or  hith- 
erto entirely  latent  disease  in  this  remaining  kidney.  It  may  even 
cause  the  perforation  into  the  pelvis  of  the  kidney  of  an  abscess 
previously  encapsulated  in  one  of  the  pyramids. 

"5.  Such  an  aggravation  of  disease  in  the  remaining  Iddney  may 
be  repeated  at  a  number  of  menstruations,  but  is,  m  the  majority  ot 
cases,  of  a  passing,  not  of  a  permanent  character.  After  such 
attacks  the  remaining  kidney  often  shows  an  improved  condition." 


524  SURGERY   OF   THE   EECTUM   AND   PELVIS. 


Suppurati'oe  Disease  of  the  Kidney. 

This  is  due  to  infection  by  one  of  the  pyogenic  bacteria  or  by  the 
tubercle  bacillus,  and  as  the  genito-urinary  tract  in  a  healthy  state 
generally  resists  infection  very  successfully,  such  infection  presup- 
poses either  traumatism  or  lowered  vitality,  which  has  prepared  the 
soil  for  their  growth. 

Any  injury  to  the  kidney  or  a  simple  congestion  may  do  this,  but 
most  frequently  the  injury  and  the  infection  come  to  it  from  the 
urethra  or  the  bladder.  Any  cause  which  prevents  the  free  escape  of 
the  urine  from  the  bladder,  as  stricture  of  the  urethra,  enlarged  pros- 
tate, or  anything  causing  injury  to  the  mucous  membrane,  as  calcu- 
lus or  operation,  prepares  the  way  for  the  entrance  of  the  pyogenic 
germ,  which  may  be  introduced  by  the  surgeon's  instruments,  or  may 
be  transmitted  through  unbroken  tissues,  as  the  bacterium  coeli 
commune  from  the  alimentary  canal. 

Once  having  gained  access  to  the  urethra  or  bladder  the  infection 
may  rapidly  extend  by  direct  continuity  of  tissue  to  the  ureter  and 
kidney. 

Keyes  has  given  this  subject  careful  study  and  writes  :  "As  early 
as  1873,  Fels  and  Ritter,  by  inoculating  the  bladders  of  dogs,  pro- 
duced ammoniacal  urine  and  cystitis,  but  only  on  condition  of  ligat- 
ing  the  urethra.  Upon  loosening  this  ligature  the  bladder  promptly 
resumed  its  condition  of  health.  So  Guy  on,  Albarran,  Guirad,  and 
many  others,  introducing  pure  cultures  of  micro-organisms  into  the 
healthy  bladders  of  animals,  fail  to  set  up  cystitis  unless  to  the  mi- 
crobic  germ  there  be  added  other  factors,  such  as  ligating  the  ure- 
thra to  produce  forced  retention,  or  wounding  the  bladder. 

"Certain  micro-organisms  have  proved  themselves  more  virulent 
than  others,  just  as  certain  subjects  are  exceptionally  susceptible  ; 
and  Schnitzler  claims  that  with  the  'urobacillus  liquefaciens  septi- 
cus'  he  can  produce  cystitis  without  tying  the  urethra. 

"But  Guyon,  Peterson,  Albarran,  and  many  others  have  repeat- 
edly proved  that  retention,  ligating  the  urethra,  trauma — not  one  of 
these  causes  alone  will  produce  cystitis,  and  that  au}^  one  plus  the 
proper  germ  will  do  it.     Straus  and  Germont  clearly  proved   that 


OPERATIONS   ON   THE   MALE   GENITO-URINAUY    ORGANS.  525 

simple  ligature  of  the  ureter,  aseptically  performed,  does  not  oc- 
casion intiammation  of  the  kidney,  but  produces  dilatation  and 
atrophy  ;  while  Charcot  and  Gombault,  with  equal  clearness,  have 
demonstrated  that  septic  ligation  of  the  ureter  does  produce  the  sup- 
purating kidney. 

"That  trauma  prepares  a  soil  for  microbic  infection  is  beautifully 
illustrated  by  Albarran.  He  showed  that  the  blood  might  be  a 
channel  of  infection  by  inoculating  one  ureter  and  ligating  it  below, 
then  finding  both  kidneys  implicated,  as  being  spots  '  minoris  resis- 
tentia' — the  ligated  side  because  of  congestion  and  direct  infection, 
the  other  on  account  of  its  hyperactivity  from  having  had  double 
work  to  do.  Then  Albarran  injected  his  bacterium  pyogenes  directly 
into  a  blood-vessel  in  a  number  of  animals,  and  got  plenty  of  em- 
bolic abscesses  in  every  instance,  but  found  the  kidneys  free  in  all 
save  one. 

"  To  study  the  effect  of  injury  plus  germs,  he  therefore  contused 
one  kidney  in  a  rabbit  and  injected  a  pure  bouillon  culture  of  bacte- 
rium pyogenes  into  its  ear.  The  next  day  this  kidney  was  already 
in  commencing  suppuration." 

Suppurative  disease  of  the  kidney  may  involve  only  the  pelvis 
(pyelitis),  or  the  pelvis  and  the  kidney  substance  (pyelonephritis). 
It  may  involve  the  substance  of  the  organ  without  implication  of 
either  the  pelvis  or  ureter,  in  which  case  there  is  true  renal  abscess, 
or  suppurative  nephritis  ;  or  it  may  be  located  in  the  cellular  tissue 
around  the  kidney  (perinephritic  abscess).  Hydronephrosis  and 
pyonephrosis  are  in  general  due  to  an  obstruction  in  the  ureter  by 
which  the  escape  of  fluid  is  prevented.  The  pelvis  becomes  distended 
with  urine  or  pus,  and  disintegration  of  the  renal  structurti  follows 
rapidly. 

It  will  often  be  impossible  to  differentiate  between  these  affections 
without  exploratory  incision,  and  although  a  simple  hydronephrosis 
may  be  relieved  by  aspiration  or  incision,  it  usually  recurs,  owing  to 
the  persistence  of  its  cause,  and  nephrectomy  is  the  final  sole  cure 
for  all  of  this  class  of  diseases. 


626  SUEGERY   OF  THE   KECTUM   AISTD   PELVIS. 

Wounds  of  the  Kid.ney. 

The  indications  for  nephrectomy  in  cases  of  wounds  of  the 
kidney  are  : 

Severe  hemorrhage. 

Tumor  in  the  region  of  the  kidney. 

Severe  cystitis. 

Traumatic  peritonitis. 

Pyonephrosis  or  hydronephrosis  from  obstruction  of  the  ureter 
by  blood-clot. 

The  hemorrhage  may  be  constant  or  intermittent,  may  come  on 
suddenly  immediately  after  the  injury  or  be  delayed  several  days, 
and  may  reach  an  extent  endangering  life. 

As  a  consequence  of  the  hemorrhage,  a  cystitis  may  be  established 
from  retained  blood-clots  which  shall  threaten  the  integrity  of  the 
remaining  kidney  by  direct  extension  of  the  inflammation  through 
the  ureter. 

Tumor  in  the  region  of  the  wounded  kidney  may  mean  extrava- 
sated  blood  around  the  organ,  pyonephrosis,  hydronephrosis,  or 
perinephritic  abscess,  and  traumatic  peritonitis  may  result  from 
direct  laceration  of  the  peritoneum. 

In  the  latter  case,  the  incision  should  be  through  the  abdomen  to 
allow  of  cleaning  out  the  peritoneum.  In  all  others,  the  operator 
has  the  choice  of  anterior  or  posterior  incision. 


CHAPTER  XXYL 

THE  SURGERY  OF  THE  URETERS. 

The  ureter  passes  under  the  peritoneum  from  tlie  kidney  to  the 
bladder,  having  an  average  length  of  about  thirteen  inches. 

Like  all  other  mucous  canals  it  varies  in  diameter  in  different 
parts.  Its  normal  calibre  is  from  three  to  five  millimetres,  but  it  is 
narrovred  at  the  point  where  it  enters  the  wall  of  the  bladder,  at  a 
short  distance  below  the  exit  from  the  pelvis  of  the  kidney,  and  at 
the  point  of  crossing  the  iliac  artery. 

In  the  male,  the  ureter  crosses  the  vas  deferens  on  the  posterior 
wall  of  the  bladder ;  in  women  it  partially  crosses  the  vagina  on  its 
anterior  wall  below  the  cervix  and  enters  the  bladder,  after  running 
nearly  three-fourths  of  an  inch  in  its  substance,  at  a  point  midway 
between  the  meatus  and  the  cervix  a  little  to  one  side  of  the  median 
line  (Fig.  274). 

Methods  of  Examination. 

Cabot  has  pointed  out  a  ready  method  of  finding  the  ureter  in  its 
course  in  the  abdomen,  from  the  fact  that  it  always  adheres  to  the 
peritoneum  when  the  latter  is  stripped  up  from  the  parts  behind  it, 
and  that  "  the  relation  of  the  ureter  to  that  part  of  the  peritoneum 
which  becomes  adherent  to  the  spine  is,  within  a  slight  range  of 
variation,  pretty  constant,  the  ureter  lying  just  oatside  the  line  of 
adhesion  ;  so  that  if  the  surgeon  has  stripped  up  the  peritoneum  and 
come  down  to  the  point  where  it  refuses  to  strip  readily  from  the 
spinal  column,  he  will  find  the  ureter  upon  the  stripped-up  perito- 
neum at  a  short  distance  outside  this  point." 

"On  the  left  side,  the  distance  from  the  adherent  point  to  the 


528 


SURGEEY   OF   THE   EECTUM   AND   PELVIS. 


U 


Fig.  274. 


Relation  of  Ureters  to  the  Cervix  Uteri. 
Ur,  ureter. 
A  C/",  uterine  artery. 
C,  cervix. 

V,  bladder  laid  open. 
Fix,  vagina  laid  open  above  to  show  cervix. 


THE   SURGERY   OF   THE   URETERS.  529 

ureter  is  from  half  an  inch  to  an  inch,  while  on  the  right  side  it  is 
somewhat  greater,  owing  to  the  ureter  being  displaced  to  the  outside 
by  the  interposition  of  the  vena  cava  between  it  and  the  spine." 

The  ureter  in  the  female  may  be  palpated  in  its  lower  part  by  the 
finger  either  in  the  vagina  or  rectum.  From  the  trigone  of  the  blad- 
der to  the  side  of  the  pelvis  it  can  be  felt  as  a  distinct  cord  by  pass- 
ing the  examining  finger  downward  and  inward  over  the  anterior 
wall  of  the  vagina.  It  may  be  followed  under  the  broad  ligament  as 
far  as  the  brim  of  the  pelvis  by  the  linger  in  the  rectum. 

The  position  of  the  intra-vesical  portions  can  also  be  seen  from 
the  vagina  by  depressing  the  posterior  wall  and  expanding  the 
anterior.  Their  position  is  marked  by  divergent  folds  starting  just 
back  of  the  neck  of  the  bladder  and  passing  backward  and  laterally 
toward  the  cervix. 

For  examination  by  palpation  Kelly  gives  the  following  direc- 
tions :  "The  finger  is  passed  into  the  vagina  behind  the  internal 
orifice  of  the  urethra,  at  the  end  of  the  rugose  promontory  on  the 
anterior  vaginal  wall,  and  carried  with  some  exertion  upward  toward 
the  brim  of  the  pelvis,  displacing  the  vaginal  wall  upward  and  out- 
ward until  the  pulp  of  the  finger  reaches  the  highest  point  it  can 
touch,  often  as  high  as  the  brim,  but  varying  according  to  the 
greater  or  less  laxity  of  the  tissues  and  their  fixation  by  pelvic  path- 
ological processes.  It  is  then  carried  downward,  stroking  the  pelvic 
wall,  carefully  estimating  the  character  of  the  structures  felt  rolling 
under  it. 

"As  soon  as  the  observer  thinks  he  has  felt  a  ureter,  he  catches 
the  cord  again  with  the  hooked  finger  and  pulls  it  down  a  little,  and 
then  slides  the  finger  first  toward  the  bladder,  where  the  ureter  is 
felt  to  lose  itself  in  the  trigone,  and  then  backward,  where  it  loses 
itself  sweeping  around  the  cervix.  I  have  found  that  in  a  certain 
number  of  cases  the  ureter  can  be  felt  most  distinctly  in  this  posi- 
tion just  in  advance  of  the  cervix,  by  placing  the  patient  on  her  left 
or  right  side,  when  the  vagina  balloons  out  and  applies  itself  closely 
to  that  side  of  the  pelvic  wall  which  lies  undermost.  Here  the  ureter 
can,  by  a  slight  effort  displacing  the  vaginal  vault  upward,  be 
hooked  and  brought  down  under  the  finger,  felt  with  the  utmost 
distinctness,  and  compressed." 


530 


SURGERY    OF   THE   RECTUM    AND    PELVIS. 


The  ureter  in  either  sex  can  be  distinctly  felt  as  it  passes  down 
over  the  brim  of  the  pelvis  just  to  the  side  of  the  promontory  of  the 
sacrum.  It  is  slightly  sensitive  to  firm  pressure,  and  on  this  account 
is  not  infrequently,  on  the  right  side,  mistaken  for  the  appendix. 


Fig.  275. 
Kelly's  Ureteial  Catheters. 


The  upper  four  inches  of  the  ureter  may  be  reached  and  explored 
extraperitoneally  by  the  lumbar  incision  for  nephrectomy  shown  in 
Fig.  273,  and  by  prolonging  this  incision  the  ureter  may  be  traced 
down  to  the  point  where  it  crosses  the  pelvic  brim.  This  is  the 
method  of  choice  for  surgical  exploration.     When  the  peritoneum  is 


THE  SURGERY  OF  THE  URETERS. 


531 


reached  it  should  be  stripped  up  witlioiit  being  opened,    and  the 
ureter  will  be  found  adherent  to  its  underside. 

Israel's  line  of  incision  for  reaching  the  abdominal  portion  of  the 
ureter  "starts  at  a  point  on  the  anterior  edge  of  the  sacro-lumbar 


Fig.  276. 
Kelly's  Ureteral  Sounds. 


mass  of  muscles  a  finger's  length  below  the  fifth  rib,  is  carried  parallel 
to  the  rib  as  far  as  its  tip,  then  turns  down  toward  the  middle  of  Pou- 
part's  ligament  till  the  line  of  the  usual  incision  for  tying  the  iliac 
artery  is  reached,  then  again  turns  toward  the  middle  line,  and  ends 
on  the  external  border  of  the  rectus  muscle." 


532  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

Gat7ieterizatio7i  of  the  Ureters  in  the  Feinale. 

This  may  be  done  by  the  sense  of  touch  alone,  or  by  direct  vision. 
The  former  is,  or  was,  Pawlik's  method,  and  the  latter  Kelly's.  The 
instruments  used  are  shown  in  Figs.  275  and  276,  and  are  a  modifica- 
tion of  Pawlik's  by  Kelly. 

The  orifice  of  the  ureter  is  normally  about  an  inch  from  the  neck 
of  the  bladder  and  from  half  to  thr^e-fourths  of  an  inch  from  the 
median  line  on  each  side.  This  point  must  be  felt  for  with  the  end 
of  the  catheter,  the  movements  of  w^iich  within  the  bladder  can  be 
seen  on  the  anterior  wall  of  the  vagina,  with  the  patient  in  the  dor- 
sal position  and  a  speculum  introduced  to  hold  back  the  posterioj 
wall.  When  once  engaged,  the  instrument  readily  follows  the  course 
of  the  ureter. 

Kelly's  method  is  much  more  certain,  having,  as  he  does,  the 
entrance  to  the  ureter  directly  in  the  field  of  vision.  The  patient  is 
placed  in  the  same  position  and  the  speculum  introduced,  the  pelvis 
being  well  elevated.  The  urethra  is  next  dilated  sufficiently  to  admit 
a  cj^lindrical  speculum,  twelve  to  fifteen  millimetres  in  diameter. 

The  interior  of  the  bladder  is  next  illuminated  with  a  forehead- 
mirror  and  electric  light,  and  the  speculum  turned  toward  the 
anatomical  point  of  the  entrance  of  either  ureter.  It  is  marked  by  a 
slight  depression,  and  by  a  darker  color  of  the  mucous  membrane. 
The  probes  shown  in  Fig.  276  may  be  used  for  sounding  for  stone  in 
the  ureter,  and  the  catheters  for  collecting  the  urine. 

On  the  left  side  in  Fig.  277  the  sound  is  shown  in  the  pelvis  of 
the  kidney  ;  on  the  right  still  in  the  ureter.  Both  project  from  the 
meatus. 

For  collecting  the  urine  from  each  kidney  separately,  to  tell 
which  one  is  diseased,  Kelly  uses  the  method  shown  in  Fig.  278. 

The  catheter  in  the  right  ureter  should  have  some  distinguishing 
mark,  to  avoid  errors  as  the  urine  is  collected.  As  the  urine  is  col- 
lected in  the  two  glasses,  any  difference  in  quantity  or  quality  be- 
comes manifest.  One  side  may  be  clear  and  abundant,  the  other 
bloody,  purulent,  and  scant.  The  catheters  are  2,  2^,  and  2^  mm.  in 
diameter,  and  30  ctm.  in  length,  constructed  of  woven  silk,  coated 
with  many  layers  of  shellac,  and  with  a  highl}^  polished  outer  sur- 


THE  SURGERY  OF  THE  URETERS. 


633 


Fig.  277. 
Sounding  the  Pelvis  of  the  Kidney. 


534 


SURGERY    OF   THE    RECTUM    AND    PELVIS. 


face.  The  end  is  blunt  and  conical,  and  lias  a  large  oval  eye,  2  ctm. 
from  the  end.  As  they  are  very  flexible,  they  are  stiffened  with  a 
wire  stylet. 

N'ot  only  is  the  presence  of  pus  in  one  or  both  kidneys  thus  made 
out  with  certainty,  but  the  amount  of  urea  in  the  urine  which  does 
not  contain  pus  shows  the  working  efficiency  of  the  other  kidney, 


Fig.  278. 
Catheterization  of  both  Ureters. 


and  indicates  something  of  the  risk  incurred  in  a  removal  of  the  dis- 
eased organ. 

The  possibility  of  treating  pyelitis  through  the  ureter  has  been 
demonstrated  by  Kelly.*  The  case  was  one  of  gonorrhoea  of  the 
ureter  and  pelvis  of  the  kidney,  with  stricture  of  the  ureter  at  its 
vesical  end.  There  was  an  extensive  collection  of  pus  in  the  ureter,' 
extending  up  into  the  pelvis  of  the  kidney. 

The  stricture  was  first  dilated  with  his  catheters  up  to  5  mm.,  the 
purulent  fluid  evacuated,  and  the  pelvis  of  the  kidney  irrigated  with 

*  Bulletin  of  the  Jolins  Hopkins  Hospital,  February,  1895. 


THE   SURGERY    OF   THE    URETERS.  535 

medicated  solutions.  The  purulent  character  of  the  secretion  and 
all  traces  of  gonococci  disappeared.  He  believes  that  this  case 
proves : 

That  stricture  of  the  ureter  can  be  diagnosticated  by  the  cysto- 
scope,  and  the  use  of  his  urethral  bougies  without  cutting  into  the 
bladder. 

That  stricture  of  the  ureter  is  capable  of  dilatation  by  the  same 
methods. 

That  a  stricture  which  has  been  dilated  daily  for  weeks  up  to  5 
mm.  will  still  hold  back  the  urine  if  the  walls  above  have  lost  their 
muscular  contractility. 

That  pyo-ureter  and  hydro-ureter  can  be  diagnosticated  by  draw- 
ing off  in  a  few  minutes  a  larger  quantity  of  fluid  than  would  gener- 
ally be  secreted  in  the  same  length  of  time. 

That  pyo-ureter  and  pyelitis  can  be  cured  by  irrigation  in  the 
manner  described  in  his  case. 

In  the  diagnosis  of  renal  calculi  Kelly  has,  however,  in  one  case, 
reached  the  point  of  absolute  certainty.''^ 

For  the  purpose  of  this  examination  he  uses  renal  catheters  and 
renal  bougies.  "  The  renal  catheters  vary  in  dittmeter  from  If  to  2^ 
mm.,  and  are  50  ctm.  (20  in.)  long.  In  all  other  respects  they  are  like 
the  ureteral  catheters  already  spoken  of.  The  catheter  is  used  in  the 
following  way  :  The  ureteral  orifice  is  exposed  and  the  catheter  intro- 
duced, say  No.  2  or  2^,  and  pushed  gradually  on  upward  until  resist- 
ance to  further  advance  is  felt.  In  general  about  from  13  to  17  ctm. 
(6  to  7  in.)  of  the  catheter  is  left  projecting  from  the  urethra.  Then 
taking  an  air-tight  syringe  with  a  tapering  metallic  point,  and 
connecting  it  by  means  of  a  piece  of  fine  rubber  tubing  with 
the  end  of  the  catheter,  strong  suction  is  exercised.  If  there  is 
any  pus  present,  this  is  often  brought  at  once  down  into  the 
syringe,  and  begins  to  flow  long  before  it  would  naturally  without 
suction.  The  suction  is  continued  until  the  renal  pelvis  is  emptied, 
and  the  fluid  obtained  is  placed  in  a  conical  graduate  for  careful 
examination." 

In  three  cases  he  has  been  able  to  diagnosticate  the  presence  of 
renal  calculi  by  discovering  in  this  fluid  a  minute,  dark-brownish  or 

*  Medical  News,  November  30,  1885. 


536 


SURGERY    OF   THE   RECTUM   AND   PELVIS. 


blackisli  sediment,  consisting  of  little  pieces  of  material  about  a  half- 
millimeter  or  less  in  diameter.  On  placing  these  under  the  microscope 
and  testing  them  they  were  found  to  be  composed  of  uric  acid.  Their 
appearance  on  the  surface  was  mammillated,  looking  like  an  aggre- 
gation of  little  masses  of  rounded  stone.     On  pressing  them  with  a 


Fig.  279. 
Stone  Caught  in  eye  of  Catheter  in  the  Pelvis  of  the  Kidney. 

needle-point  they  were  found  to  be  quite  coherent,  each  separate  par- 
ticle bending  and  breaking  under  pressure. 

Instead  of  a  catheter  he  proposes  the  use  of  bougies  coated  with 
dental  wax,  the  surface  of  which  will  scratch  upon  contact  with  any 
calculous  matter  in  the  pelvis  of  the  kidney. 

Should  immediate  exploration  of  the  ureters  be  necessary  in  any 


Fig.  280. 
Same  Stone  Magnified  Eighteen  Times,  sho-w-ing  Broken  Surface. 


case  and  the  surgeon  have  not  sufficient  skill  in  this  method  of  ex- 
amination to  succeed  with  it,  their  orifices  in  the  trigone  of  the  blad- 
der may  always  be  exposed  by  an  incision  through  the  anterior  wall 
of  the  vagina.  Through  such  an  incision  the}^  can  be  plainly  seen 
and  sounded  or  catheterized,  and  the  incision  may  be  closed  when  the 
examination  is  finished  without  harm. 


THE   SURGERY    OF   TPIE   URETERS. 


537 


Catheterism  in  the  Male. 

The  following  description  is  taken  from  Meyer  :  * 
"1.  The  shank  of  the  cystoscope  carries  a  straight  groove,  which 
can  be  transformed  into  a  canal  with  the  help  of  a  movable  lid  (la.) 
with  a  handle  (H).  It  is  to  receive  the  ureter 
catheter  (U.  C).  The  outer  end  of  this  canal 
(0.  E.)  projects  over  a  semi-circular  hard-rub- 
ber plate  (PI.)?  which  forms  a  convenient  han- 
dle, and  being  situated  about  an  inch  and  a  half 
away  from  the  ocular  end  of  the  telescope  (O.), 
can  easily  be  reached  by  the  operator's  hands. 
The  vesical  end,  about  six  millimeters  in  front 
of  the  prism  (Pr.),  is  worked  out  in  such  a  way 
that  the  ureter  catheter,  emerging  into  the  blad- 
der, when  pushed  from  the  outside,  forms  with 
the  shank  of  the  cystoscope  an  angle  of  forty- 
five  degrees.  By  this  means  we  are  enabled  to 
enter  the  ureteral  orifice  with  great  ease,  as  the 
vesical  end  of  the  ureter  and  the  fundus  of  the 
bladder  form  an  angle  of  about  the  same  size. 
But  the  angle  of  forty-five  degrees  between  the 
catheter  and  shank  is  produced  only  if  the  lid 
be  pushed  in  as  tightly  as  possible.  The  canal 
is  situated  on  the  concave  side  of  the  cystoscope, 
the  one  which  carries  prism  and  lamp  (La.). 
This  is  a  very  wise  ari-angement  and  decidedly 
distinguishes  Casper's  C3^stoscope  from  Bren- 
ner's and  Boisseau  du  Rocher's.  Both  the 
latter  carry  the  straight  tube  on  the  convex  side, 
and,  having  no  prism,  force  the  cystoscopist  to 
inspect  the  ureteral  opening  through  a  simple 
straight  telescope.  In  order  to  do  this  the  han- 
dle naturally  has  to  be  raised  until  it  is  almost 
vertical.      For  obvious  reasons  the  result  thus  ^f^ 

generally  was  very   unsatisfactory.     But  in  let-  ^^^^-  ^S'- 

Casper' s    Ureter 
*  New  York  Medical  Journal,  March  21,  1896.  Cystoscope. 


538  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

ting  the  catheter  pass  out  right  in  front  of  the  prism,  its  tip,  some- 
what magnified,  always  remains  under  the  control  of  our  eyes,  and 
we  handle  the  instrument  just  as  we  always  use  Nitze's  cystoscope 
for  the  inspection  of  the  fundus  of  the  bladder. 

"2.  The  lamp  is  situated  behind  the  prism  in  the  longitudinal  axis 
of  the  instrument — Lohnstein's  modification  (see  figure).  The  other 
cystoscopes  carry  the  lamp  in  the  tip  of  the  beak.  Lohnstein 
alleges  for  his  modification  the  following  special  advantages  over 
Nitze's  original  instrument: 

"(a)  Foreign  bodies  in  the  bladder,  larger  stones,  and  tumors, 
that  often  have  the  tendency  to  fill  out  the  concavity  of  the  beak  of 
Nitze's  cj^stoscope,  and  will  then  not  be  seen  on  account  of  not  being 
illuminated,  can  be  nicely  observed. 

"(6)  Tumors  situated  at  the  side  and  above  the  internal  ure- 
thral orifice  will  not  escape  the  inspecting  eye.  These  will  generally 
not  come  into  view  by  performing  cystoscopy  with  Nitze's  instru- 
ment No.  1. 

"(c)  Beaks  of  different  shape  and  length  can  be  made  and 
screwed  on  the  instrument. 

"3.  The  beak  of  the  instrument  (B.)  is  made  in  one  piece  with 
that  portion  which  carries  the  lamp. 

"The  arrangements  as  described  under  Nos.  2  and  3  permit 
of  shaping  the  beak  according  to  necessity  (hypertrophy  of  the 
prostate,  etc.).  Patients  will  thus  more  rarely  experience  the 
slight  burning  sensation  if  the  tip  of  the  beak  should  touch  the 
fundus. 

"4.  If  the  lid  that  covers  the  canal  be  pulled  out,  a  straight  metal 
mandrel  (M.)  can  be  inserted  into  the  groove.  By  doing  this  the 
small  catheter  which  had  been  pushed  through  the  canal  into  the 
ureter  is  lifted  out  of  the  groove  and  thus  liberated.  Now  the  cys- 
toscope can  be  withdrawn,  while  the  catheter  remains  in  situ.  The 
latter  is  an  English  web  catheter  of  No.  4  French  gauge.  It  is  sixty 
centimetres  (twenty-three  inches  and  a  half)  long.  A  long,  thin 
wire  mandrel  obstructs  its  lumen  up  to  about  two  inches  from  its 
tip.  The  catheter  is  flexible,  yet  has  sufficient  stiffness  to  enter  the 
vesicle  end  of  the  ureters,  and  to  pass  upward  to  the  pelvis  of  the 
kidney  if  gently  pushed  from  the  outside. 


THE   SURGERY    OF   THE   URETERS.  639 

"5.  Tlie  ocular  lens  of  the  telescope  is  not  in  the  same  axis  as 
the  other  lenses.  It  is  moved  to  a  place  two  centimetres  below  the 
canal  described  above  under  No.  1.  This  is  done  to  enable  the  cys- 
toscopist  to  handle  the  lid  of  the  canal  and  the  steel  mandrel  with 
convenience  and  ease,  and  to  push  forward  the  ureter  catheter  or  its 
substitutes  in  a  straight  line.  The  picture  is  reflected  to  the  ocular 
lens  with  the  help  of  a  double  prism.  The  view  oi  the  interior  of 
the  bladder  is  nevertheless  just  as  brilliant  and  satisfactory  as  when 
it  is  seen  through  the  other  cystoscopes. 

"The  shape  of  the  shank  is  oval,  not  round;  its  size,  'No.  24 
French  gauge.  It  passes  a  urethra  of  this  dimension  without  difii- 
oulty.  The  electric  current  is  conveyed  to  the  instrument  by  slip- 
ping a  double  perforated  semi-circular  hard-rubber  plate  over  the 
two  projecting  wires,  which  are  fastened  on  the  hard-rubber  handle 
of  the  instrument  {+  and  — ).  A  screw  (S.)  makes  and  breaks  the 
current. 

"The  directions  for  using  the  instrument  given  by  Meyer  are  as 
follows : 

"1.  Wash  and  cocainize  the  bladder  according  to  well-known 
rules. 

"  2.  Fill  the  bladder  with  from  five  to  seven  ounces  of  clear  fluid. 
It  is  necessary  to  inject  a  little  more  than  the  usual  average  amount 
for  a  cystoscopic  examination — viz.,  five  ounces — because  there  is 
some  continuous  leakage  alongside  the  ureter  catheter.  Of  course 
the  latter  cannot  fit  in  the  canal  as  snugly  as  a  mandrel  does;  it  has 
to  remain  freely  movable.  Consequently  there  must  be  leakage,  as 
the  intravesical  pressure  is  greater  than  the  atmospheric.  The  fluid 
in  the  bladder  is  therefore  slowly  ebbing  away.  By  placing  the 
patient  in  Trendelenburg's  posture  of  about  twenty-five  degrees  dur- 
ing the  examination,  we  can  reduce  this  leakage  a  good  deal ;  also 
by  slipping  over  the  external  entrance  to  the  canal  a  short  rubber 
tube  of  very  small  calibre,  just  large  enough  to  permit  of  moving  the 
ureter  catheter.  Until  the  ureteral  openings  have  been  found  this 
tube  should  be  well  pressed  against  the  catheter.  A  simple  sling  of 
a  thread  will  also  suffice.  On  the  other  hand,  it  is  not  wise  to  fill 
the  bladder  with  too  much  fluid.  Six  ounces  should  be  the  average 
amount.     A  beginner  may  probably  do  well,  in  order  to  save  time 


540  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

and  to  succeed,  first  to  use  the  ordinary  cystoscope  for  ascertaining 
the  situation  of  the  mouth  of  the  ureters  and  then  to  introduce  the 
ureter  cystoscope. 

"  3.  Push  the  ureter  catheter  down  to  the  internal  opening  of  the 
canal,  the  lid  of  the  latter  being  well  in  place  ;  introduce  the  instru- 
ment. 

"4.  As  soon  as  the  interior  of  the  bladder  has  been  satisfactorily 
inspected  and  the  ureteral  openings  have  come  into  view,  approach 
one  of  them.  A  trained  cystoscopist  knows  how  to  do  this.  He 
slightly  raises  the  handle  of  the  instrument  and  carries  it  over  to  the 
opposite  side  of  the  patient,  at  the  same  time  pushing  it  in  a  little  or 
pulling  it  out  until  the  orifice  is  in  the  focus.  By  bringing  the  prism 
as  near  to  it  as  possible,  we  greatly  magnify  the  tiny  hole,  and  can 
observe,  in  a  beautifully  clear  manner,  how  the  catheter  becomes  en- 
gaged in  the  opening,  and,  if  pushed  from  outside,  passes  on  and  on. 

"  I  have  found  it  practicable  to  pull  out  the  lid  a  little,  say  a  quar- 
ter of  an  inch,  before  pushing  the  catheter  out  of  the  canal  into  the 
bladder.  Its  rather  delicate  tip  is  thus  better  preserved,  and  not 
roughened  by  the  borders  of  the  narrow  hole. 

"The  lid  must  then  at  once  be  pushed  back  into  place.  As  men- 
tioned above,  this  is  absolutely  necessary  in  order  to  let  the  catheter 
emerge  at  an  angle  of  forty -five  degrees.  If  this  rule  is  not  adhered 
to  the  catheter  will  not  enter  the  ureter,  no  matter  how  we  may  turn 
or  push  or  pull  the  cystoscope. 

"5.  Catheterism  of  the  ureter  having  been  successful,  the  wire 
mandrel  is  withdrawn  from  the  catheter.  Urine  generally  at  once 
begins  to  fiow,  drop  by  drop,  at  intervals.  I  should  strongly  advise  al- 
ways to  withdraw  the  mandrel  as  soon  as  the  catheter  has  entered  the 
lower  end  of  the  ureter  for  about  one  to  two  inches :  this  to  find  out, 
as  long  as  the  cystoscope  is  in  the  bladder,  whether  the  lumen  of  the 
catheter  is  not  obstructed.  As  soon  as  the  urine  fiows,  one  glance 
through  the  instrument  will  tell  us  whether  the  catheter  is  in  its 
proper  place.  If  we  push  the  catheter  farther  up  toward  the  pelvis 
of  the  kidney  and  lift  it  out  of  the  canal,  pull  out  the  cystoscope  and 
then  withdraw  the  mandrel,  our  entire  procedure  may  prove  to  be  a 
failure." 

As  in  the  case  of  women,  so  in  men  the  ureters  may  be  catheterized 


THE   SURGERY    OF   THE   URETERS.  541 

through  a  supra-pubic  incision  into  the  bladder,  and  the  risks  of 
such  instrumentation  will  not  be  great  when  the  operation  is  per- 
formed with  care. 

Wounds  and  Lacerations  of  tTie  Ureter.     ^ 

Direct  injury  to  the  ureter  alone  by  external  violence  is  so  rare  an 
occurrence  that  its  clinical  history  has  never  been  written  with  any 
completeness.  Several  cases  of  extra-peritoneal  puncture  and  lacera- 
tion have  been  reported,  however,  and  the  rules  for  treatment  are 
fairly  well  determined. 

The  diagnosis  can  usually  only  be  made  by  the  escape  of  urine 
from  the  ureter  into  the  cellular  tissue  and  the  formation  of  a  tumor. 
This  may  require  a  number  of  days. 

Incision  into  such  a  tumor  might  allow  of  suture  of  the  ureter, 
but  it  would  probably  be  found  in  such  a  condition  as  to  militate 
against  such  an  attempt,  and  the  operative  interference  would  end 
by  the  establishment  of  a  urinary  fistula  in  the  loin,  with  suture  of 
the  ureter  to  the  skin,  if  possible  ;  or  in  extirpation  of  the  kidney 
were  the  opposite  one  in  sound  condition. 

When  the  loss  of  substance  in  the  ureter  is  too  great  to  admit  of 
closure  of  the  wound,  the  end  should  be  implanted  in  the  skin 
incision,  or  into  the  bladder.  Implantation  into  the  bowel  leads 
naturally  to  suppurative  disease  of  the  kidney  by  infection.  Im- 
plantation into  the  skin  may  be  found  such  an  annoyance  that  sub- 
sequent nephrectomy  will  be  preferred  after  the  condition  of  the  op- 
posite kidney  has  been  determined,  and  the  existence  of  the  urinary 
fistula  renders  this  easy. 

Injury  to  the   Ureters  in  Pelvic  Operations. 

Some  of  the  most  brilliant  work  of  the  present  day  is  being  ^done 
in  the  repair  of  these  by  no  means  uncommon  injuries,  which  were 
formerly  supposed  to  be  relievable  only  by  extirpation  of  the  kidney. 
The  operations  are  long  and  difficult,  the  secondary  ones  much  more 
so  than  the  primary,  and  therefore  if  an  injury  to  the  ureter  is  dis- 
covered at  the  time  it  is  made  it  should  be  remedied  at  once. 


642  SUKGERY   OF   THE   RECTUM   AND   PELVIS. 

Van  Hook's  operation  consists  in  ligating  the  lower  end,  making- 
a  longitudinal  incision  below  the  ligature  and  implanting  the  upper 
end  laterally  as  in  a  lateral  implantation  of  the  intestine,  fastening 
the  parts  with  fine  silk  sutures.  Longitudinal  tears  are  sutured  with 
fine  silk. 

When  the  injury  has  been  so  extensive  that  suturing  is  impossible 
the  lower  end  should  be  tied  and  the  upper  transplanted  into  the 
bladder  through  a  slight  incision  and  sutured  there.  A  long  pair  of 
delicate  forceps  passed  into  the  bladder  through  the  urethra  may  be 
serviceable  in  holding  the  ureter  within  the  incision  in  the  bladder 
wall  while  the  suturing  is  being  done. 

Secondary  operations  are  the  same  as  the  primary  ones,  but  much 
more  difiicult  from  the  fact  that  the  ureter  may  be  lost  in  pelvic  ad- 
hesions and  cicatrices  from  which  it  must  be  dissected  out  before 
suturing  is  possible. 

When  no  communication  can  be  established  with  the  bladder  the 
best  disposition  to  be  made  is  to  suture  the  end  of  the  ureter  to  the 
abdominal  incision. 

Ureteritis. 

The  diagnosis  of  an  inflammation  of  the  ureter  rests  upon  localized 
pain,  enlargement  and  hardening  of  the  organ  as  shown  on  palpa- 
tion, frequent  micturition,  and  pus  in  the  urine.  Although  the  con- 
dition may  be  amenable  to  local  treatment  by  Kelly's  method,  when 
it  reaches  the  point  of  causing  hydronephrosis  the  usual  treatment 
has  been  the  establishment  of  a  urinary  fistula  from  the  pelvis  of  the 
affected  kidney. 

Ureteral  Stricture.     ■ 

This  may  be  due  either  to  exudation  caused  by  ureteritis,  to  trau- 
matism, the  pressure  of  a  pelvic  tumor,  or  to  calculus.  It  may  be 
diagnosticated  by  the  use  of  the  bougies  or  catheters  already  de- 
scribed, and  the  collection  of  a  considerable  quantity  of  urine  more 
rapidly  than  it  is  naturally  secreted  as  soon  as  the  catheter  has  passed 
the  stricture  ;  or  by  the  hydronephrosis  which  results.     The  cases 


THE   SURGERY   OF   THE   URETERS.  543 

due  to  thickening  or  slight  traumatism  may  be  curable  by  gradual 
dilatation. 

The  diagnosis  of  the  exact  point  at  which  the  stricture  is  located 
will  be  impossible,  except  by  catheterization,  without  exploratory 
incision.  The  preferable  incision  for  this  purpose  is  the  lumbar  one, 
as  by  it  the  pelvis  of  the  kidney  is  exposed  and  catheterization  may 
be  practised  from  above  downward.  The  normal  ureter  will  admit  a 
bougie  of  number  9  to  12  French. 

The  treatment  consists  in  : 

Dilatation. 

Incision  and  Suture. 

Resection. 

Dilatation  may  be  from  below^  by  Kell3^'s  instruments  (the  pref- 
erable method)  or  from  above  at  the  time  of  exploration. 

The  operation  by  incision  and  suture  is  the  same  as  that  prac- 
tised in  stricture  of  the  pylorus,  the  incision  being  longitudinal  and 
the  suturing  transverse. 

When  the  stricture  is  located  near  the  pelvis  of  the  kidney,  as 
proved  by  the  sound,  the  part  may  be  resected  and  the  end  of  the 
ureter  transplanted  to  the  pelvis.      This  has  been  successfully  done. 

When  the  obstruction  is  found  farther  away  from  the  kidney, 
the  ureter  should  be  opened  and  probed  both  upward  and  down- 
ward to  test  its  permeability  in  other  parts,  and  suture  or  implanta- 
tion practised  after  the  stricture  has  been  excised. 

When  the  obstruction  is  near  the  bladder  and  dilatation  ineffect- 
ual, it  may  be  excised  by  a  transperitoneal  incision  and  the  ureter 
transplanted  into  the  bladder-wall,  as  is  the  usual  procedure,  then 
the  ureter  is  injured  in  pelvic  operations. 


Ureteral  Calculus. 

The  favorite  sites  of  impaction  for  ureteral  calculus  are  either 
near  the  pelvis  of  the  kidney  or  near  the  vesical  opening.  When  in 
the  latter  position,  it  can  be  removed  either  throngh  the  urethra 
after  dilatation,  or  by  an  incision  into  the  bladder  through  the  va- 
gina.    When  it  is  located   near  the  kidney,   the  usual  incision  for 


644  SURGERY   OF   THE   RECTUM   AND    PELVIS. 

reaching  that  organ  is  preferable,  as  by  it  the  ureter  can  easily  be 
followed  for  a  considerable  distance. 

If  a  stone  be  impacted  in  the  upper  part  of  the  ureter  it  can 
generally  be  felt  through  this  incision.  If  it  be  impacted  in  the 
pelvic  portion,  it  cannot,  as  a  rule,  be  reached  through  an  extra-peri- 
toneal incision,  unless  it  be  through  the  vagina  and  bladder. 

When  the  stone  is  located,  it  should  be  removed  by  longitudinal 
incision  and  the  ureter  closed  by  a  Lembert  suture,  as  is  so  often 
done  in  calculi  in  the  hepatic  ducts.  Suturing  is  more  necessary  by 
an  intra-peritoneal  incision  than  in  the  extra-peritoneal  operation. 
In  the  latter  case  the  urinary  fistula  v^hich  remains  will  generally 
close  spontaneously. 


CHAPTER  XXVII. 


APPENDICITIS. 


The  intelligent  surgical  treatment  of  appendicitis  consists  mucli 
more  in  knowing  when  to  operate  than  in  opening  the  abdomen  ;  and 
to  know  this  implies  a  knowledge  of  the  pathology  and  symptom- 
atology of  the  disease  in  its  various  forms  and  stages. 

The  question  of  operation  is  easily  solved  if  one  believes  with 
Morris,  that  "  the  best  surgical  operations  for  prompt  removal  of  an 
infected  appendix  are  now  less  to  be  dreaded  than  a  mild  attack  of 
appendicitis."  And  this  may  be  true.  Certainly  the  man  who  oper- 
ates in  every  case,  as  soon  as  a  diagnosis  is  made,  will  save  more  lives 
than  he  who  postpones  his  operations  too  long.  But  neither  the 
medical  nor  surgical  world  is  as  yet  ready  to  accept  this  easy  solution 
of  the  question  when  to  operate,  and  for  the  present  we  must  be 
guided  in  our  surgical  interference  by  the  character  and  degree  of 
appendicitis,  and  not  by  the  bare  fact  that  some  form  of  appendici- 
tis exists. 

In  every  case  of  appendicitis  there  is  a  combined  morbid  process, 
consisting  first  of  a  catarrhal  inflammation  of  the  mucous  membrane 
and  second  of  a  bacterial  invasion.  The  septic  germ  most  commonly 
found  is  the  bacterium  coeli  communis,  which  is  always  present  in 
the  alimentary  canal,  but  which  seems  powerless  to  set  up  a  septic 
process  in  the  canal  itself  without  the  previous  existence  of  some 
lesion  which  forms  a  bed  for  its  attack  and  culture. 

Leaving  out  of  consideration  the  cases  of  appendicitis  which  may 
be  due  to  typhoid  fever,  syphilis,  tuberculosis,  and  actinomycosis, 
each  of  which  may  result  in  perforation  of  the  appendix  with  peri- 

35 


546  SURGERY    OF   THE   RECTUIM    AND    PELVIS. 

tonitis  and  septic  poisoning,  the  cause  of  tlie  primary  catarrhal  in- 
flammation may  be  difiicult  and  even  impossible  to  detect.  The  fact 
that  the  appendix  is  a  rudimentary  and  very  poorly  nourished  or- 
gan may  have  influence  ;  as  may  also  the  fact  that  its  mesentery  is 
very  short  and  liable  by  being  twisted  to  interfere  with  the  slight 
nourishment  it  normally  receives. 

There  is  also  little  doubt  but  that  any  catarrhal  inflammation 
originating  in  the  caput  coli,  as  from  the  presence  of  scybala,  may 
be  propagated  to  the  appendix  by  direct  continuity  of  tissue. 

Traumatism  from  violent  exertion,  excess  in  eating,  and  exposure 
to  cold  have  each  been  called  upon  to  account  for  its  proportion  of 
cases. 

More  definitely,  however,  we  have  as  active  and  palpable  causes 
the  presence  of  fecal  concretions  which  have  found  their  way  into 
the  appendix,  and,  being  unable  to  escape,  have  increased  in  size  till 
their  pressure  caused  the  necessary  traumatism  ;  the  presence  of 
foreign  bodies  ;  mechanical  obstruction  or  entire  obliteration  of  the 
lumen  of  the  organ  b}^  bending  or  adhesions ;  and  smallness  of  the 
Ccecal  orifice  preventing  the  escape  of  secretions. 

Clinically,  however,  the  most  active  of  all  causes  is  the  occurrence 
of  a  previous  attack. 

In  acute  cases  the  original  catarrhal  inflammation  plus  the  bac- 
terial invasion  causes  ulceration  of  the  mucous,  submucous,  and  ade- 
noid layers  of  the  appendix  up  to,  or  through,  the  peritoneal  coat. 
When  the  process  is  arrested  at  the  peritoneal  covering  the  latter 
will  show  the  signs  of  slight  inflammation — roughening,  and  slight 
adhesions,  sufficient  to  attach  it  to  anything  with  which  it  may  be  in 
contact,  but  generally  easily  broken  down.  Such  a  process  is  ca- 
pable of  resolution,  or  may  result  in  the  chronic  form  of  the  disease. 

When,  on  the  other  hand,  the  peritoneum  is  invaded  in  the  orig- 
inal process,  there  will  result  either  a  localized  surrounding  inflam- 
mation, or  perforation  with  septic  peritoneal  infection,  or  fecal  ex- 
travasation. 

The  size  and  location  of  the  perforation  will  vary  with  the  exciting 
cause  of  the  process  and  its  intensity.  The  rapidity  and  amount  of 
the  extravasation  will  depend  upon  the  site  of  the  perforation,  its 
extent,  and  the  size  of  the  lumen  of  the  appendix.     The  entire  organ 


APPENDICITIS.  547 

wicli  its  mesentery  may  be  gangrenous,  and  may  separate  close  to  the 
csecal  attachment.     Even  the  caecum  itself  may  be  involved. 

In  chronic  cases  of  infection  v^ithout  perforation  of  the  peritoneal 
layer  the  appendix  becomes  thickened,  hard,  erect,  and  friable.  It 
is  increased  in  size  so  that  it  may  usually  be  detected  by  abdominal 
palpation.  In  some  cases  old  and  very  dense  adhesions  may  exist 
between  it  and  neighboring  organs.  Cicatricial  stenosis  may  also 
occur  at  one  or  more  points,  and  may  involve  the  entire  lumen,  caus- 
ing the  club-shaped  and  cystic  appendices  occasionally  seen. 

Clinically,  the  surgeon  is  called  upon  to  distinguish  between  four 
different  forms  or  stages  of  the  disease  by  the  symptomatology. 
These  are  : 

Acute  appendicitis  without  perforation. 

Chronic  (recurrent)  appendicitis. 

Acute  appendicitis  with  perforation  and  localized  peritonitis. 

Acute  appendicitis  with  extravasation  and  general  septic  peri- 
tonitis. 

If  this  diagnosis  could  always  be  made  the  questions  when  not  to 
operate  and  when  to  operate  would  be  easily  answered  in  any  special 
case. 

Symptoms. 

All  symptoms  may  be  so  light  as  to  be  unrecognized  until  the  peri- 
toneum is  attacked  and  a  localized  or  general  peritonitis  manifests 
itself.     This  is  not,  however,  the  usual  course. 

Grenerally  the  first  symptoms  will  be  pain,  vomiting,  tenderness 
on  pressure  over  the  appendix,  rigidity  of  the  muscular  wall,  and 
fever.  In  non-perforating  cases  these  symptoms  will  gradually  sub- 
side without  the  formation  of  tumor. 

In  perforating  cases  the  signs  of  peritonitis  will  follow  those  of 
inflammation  of  the  appendix,  and  these  will  vary  according  to  the 
degree  and  character  of  the  peritonitis. 

When  the  peritonitis  is  localized,  and  there  is  a  formation  of  pus, 
tumor  will  appear  on  the  third  or  fourth  day  in  the  iliac  fossa  if  the 
pus  is  near  the  surface,  otherwise  no  tumor  may  be  distinguishable, 
or  it  may  only  be  found  by  rectal  examination. 


548  SURGERY    OF   THE   RECTUM   AND    PELVIS. 

In  general  peritonitis  from  perforation  or  extravasation  the  pain 
rapidly  extends  from  tlie  site  of  the  appendix  over  the  entire  abdo- 
men, and  the  signs  of  profound  septic  poisoning  rapidly  develop. 
These  are  vomiting  (perhaps  with  fecal  odor) ;  obstinate  constipation 
from  intestinal  paralysis ;  albuminuria  and  suppression  of  urine  ; 
high  and  feeble  pulse  ;  anxious  countenance  ;  normal,  slightly  raised, 
■or  subnormal  temperature  ;  swollen  abdomen  with  infiltration  of  the 
walls  ;  and  hiccough.    Generally  death  follows  in  three  or  four  days. 

It  will  often  be  impossible  to  decide  by  the  most  careful  study  of 
the  symptoms  whether  the  morbid  process  has  or  has  not  involved 
the  peritoneum,  and  as  it  is  upon  this  factor  that  the  question,  for  or 
against  operation,  rests,  the  difficulty  is  manifest.  All  of  the  sjaup- 
toms  which  indicate  perforation,  such  as  high  pulse  and  temperature, 
board-like  hardness  of  the  abdominal  wall,  pain,  and  vomiting,  may 
be  present  in  the  non-perforative  form  of  disease ;  and  they  may  all 
be  less  marked,  or  some  of  them  may  be  absent,  after  pus  has  already 
formed  in  the  peritoneum. 

Perhaps  the  best  working  guide  in  practice  will  be  the  general 
condition  of  the  patient  at  the  end  of  the  first  thirty-six  hours  after 
the  onset  of  the  attack.  At  that  time  a  simple  catarrhal  appendicitis 
should  begin  to  improve  and  the  symptoms  should  subside.  Should 
:they  not  do  so  an  operation  is  justified  without  waiting  for  them  to 
ibecome  more  severe. 

Diagnosis. 

General  or  localized  peritonitis,  even  in  men,  is  not  always  due  to 
appendicitis.  In  women  the  possibility  of  rupture  of  pus  tubes,  or 
ovaries,  or  of  an  extra-uterine  pregnancy,  should  never  be  lost  sight 
of,  and  in  men  it  is  possible  that  the  infectious  process  may  have 
started  from  some  other  organ  or  some  other  part  of  the  alimentary 
canal.  In  one  of  my  own  cases  a  cancerous  perforation  of  the  stom- 
ach with  general  peritonitis  could  not,  I  believe,  have  been  distin- 
guished from  appendicitis  before  the  incision,  so  board -like  were 
the  abdominal  muscles  and  so  severe  the  onset  of  the  disease. 

In  another  case  the  tumor  formed  b}^  an  ectopic  pregnancy  was 
only  distinguishable  from  appendicitis  after  abdominal  section. 


APPENDICITIS.  549 


Operatim  Treatment. 

There  are  a  few  general  principles  which  are  of  great  value  in 
deciding  the  question  of  operation. 

Tumor  in  the  neighborhood  of  the  appendix,  with  the  symptoms 
of  an  acute  attack,  always  calls  for  immediate  operation,  and  pus, 
though  it  may  be  in  small  quantity,  will  almost  invariably  be  found 
when  tumor  is  present. 

Collections  of  pus,  which  cannot  be  felt  through  the  abdominal 
wall  in  the  neigliborhood  of  the  appendix,  may  sometimes  be  felt 
through  the  rectum  or  vagina  and  not  infrequently  evacuate  them- 
selves through  these  channels. 

Great  pain  and  tenderness  over  the  caecum,  with  muscular  rigidity 
of  the  abdominal  wall,  are  signs  of  peritonitis,  as  well  as  of  appen- 
dicitis, and  call  for  operation. 

In  doubtful  cases  high  pulse  is  a  more  reliable  indication  of  septic 
poisoning  than  high  temperature. 

Constant  vomiting,  with  or  without  fecal  odor,  is  an  indication 
for  operation. 

x^fter  complete  recovery  without  operation  from  a  first  attack,  the 
commencement  of  a  second  attack  may  be  awaited  before  operating. 

When  after  recovery  from  a  first  attack  either  a  swollen  appendix 
or  a  tumor  remains,  operation  should  be  advised,  without  waiting  for 
a  second  attack. 

In  recurrent  appendicitis,  operation  is  always  indicated  between 
the  attacks,  and  also  at  the  beginning  of  every  fresh  attack. 

Operation  is  called  for  when  symptoms  persist  after  an  operation 
in  wliich  pus  has  simply  been  evacuated,  but  the  appendix  has  not 
been  removed.  In  such  cases  the  appendix  frequently  acts  as  a 
source  of  recurrent  trouble,  and  the  rule  for  treatment  is  the  same  as 
in  that  of  recurrent  appendicitis,  in  which  pus  does  not  happen  to 
have  once  been  evacuated. 

The  real  contra-indications  to  operating  are  that  in  many  of  the 
non-perforating  cases  operation  is  proved  to  be  unnecessary  by  the 
recovery  of  the  patient  ;  and  that  when  the  case  has  progressed  to 
the  point  where  adhesions  have  walled  off  the  septic  process  from  the 


550  SURGERY   OF   THE   RECTUM   AND   PELVIS. 

general  peritoneal  cavity,  it  is  exceedingly  dangerous  to  break  down 
this  bearer  by  surgical  interference. 

The  variety  of  operation  differs  according  to  the  character  of  the 
case.  Simple  catarrhal  appendicitis,  vs^hether  a  first  attack  or  recur- 
rent, requires  one  technique,  circumscribed  abscess  another,  and  dif- 
fuse peritonitis  a  third. 

Considering  the  simpler  variety  first,  the  incision  should  be  about 
two  inches  in  length  and  should  cross  a  line  from  the  anterior  su- 
perior spinous  process  to  the  umbilicus  at  a  point  about  an  inch  and 
a  half  from  the  bone.  In  this  way  the  sheath  of  the  rectus  muscle 
will  not  be  opened. 

When  the  peritoneum  has  been  opened  one  finger  is  introduced 
through  the  wound  to  search  for  the  appendix.  Should  this  not  be 
adherent  it  may  be  brought  out  of  the  incision  and  the  latter  closed 
with  a  sponge.  Should  it  be  impossible  to  discover  it  a  systematic 
search  should  be  made  by  bringing  the  ascending  colon  to  the  in- 
cision and  following  the  longitudinal  band  on  its  unattached  border. 
This  band  leads  directlj^"  to  the  base  of  the  appendix. 

Should  the  appendix  be  firmly  adherent  it  may  be  best  and  in- 
deed necessary  to  enlarge  the  opening  so  that  the  operation  may  be 
aided  by  sight  as  well  as  touch,  for  adhesions  should  not  be  broken 
without  due  caution  as  to  both  bleeding  and  perforation. 

When  the  appendix  has  been  delivered  through  the  incision  its 
mesentery  is  to  be  tied  as  in  resection  of  any  piece  of  gut.  This  may 
be  done  with  one  or  more  ligatures  before  cutting  it  loose,  or  the 
mesentery  may  be  separated  from  the  appendix  with  scissors  close  to 
the  latter,  and  bleeding  points  secured  as  they  show  themselves. 

The  next  step  depends  upon  whether  the  appendix  is  to  be  liga- 
tured and  amputated,  or  amputated  and  the  stump  invaginated 
within  the  colon.  Either  course  may  be  followed,  as  the  operatoi 
chooses. 

In  the  former  case  a  circular  flap  of  peritoneum  should  be  dis- 
sected down  after  an  incision  has  been  made  around  the  appendix 
about  one-third  of  an  inch  from  the  colon.  When  the  peritoneum 
has  been  dissected  downward  for  about  a  quarter  of  an  inch  the 
appendix  should  be  ligatured  with  fine  strong  catgut  and  cut  away, 
the  stump  being  treated  with  pure  carbolic  acid.     The  flap  of  peri- 


APPENDICITIS.  551 

toneum  is  then  drawn  up  over  the  stump  and  sutured  with  three  or 
four  Lembert  sutures  of  fine  silk. 

When  the  stump  of  the  appendix  is  to  be  invaginated  it  should 
be  amputated  within  half  an  inch  of  its  attachment,  every  precaution 
being  taken  to  protect  the  general  peritoneum.  Holding  the  colon 
firmly  between  the  thumb  and  finger  of  the  left  hand,  the  edge  of 
the  stump  is  seized  with  dissecting  forceps  and  turned  into  the  lumen 
of  the  appendix.  This  is  not  generally  difficult  after  a  little  experi- 
ence, but  should  it  be  found  so,  the  forceps  may  be  inserted  into  the 
lumen  of  the  stumjD  and  carried  as  far  as  the  insertion  of  the  appen- 
dix, and  gentle  dilatation  practised.  After  one  or  two  trials  the 
stump  may  be  invaginated  and  the  caecum  closed  over  it  by  three 
or  four  Lembert  sutures. 

Dawbarn's  method  is  the  same,  except  that  he  surrounds  the  base 
of  the  appendix  with  a  purse-string  suture  in  the  caput  coli  before 
inverting  the  stump.  After  inversion  as  above  a  tightening  of  the 
purse-string  accomplishes  the  same  end  as  the  Lembert  sutures. 

Tlie  advantage  of  invagination  consists  in  the  absence  of  any 
sloughing  stump  left  in  the  general  peritoneal  cavity,  which  may 
form  painful  and  dangerous  adhesions  to  adjacent  coils  of  intestine. 

The  ligation  of  the  stump  without  inversion,  or  covering  with  a 
peritoneal  layer,  has  been  followed  by  subsequent  fatal  peritonitis 
from  sloughing  at  the  point  of  ligation.  Li  such  cases  it  is  not  suf- 
ficient to  disinfect  the  end  of  the  stump,  but  the  calibre  of  the  appen- 
dix should  also  be  cauterized.  Inversion  is,  however,  the  operation 
of  choice,  and  is  almost  always  practicable  if  the  orifice  of  the  appen- 
dix be  previously  dilated  by  the  introduction  of  a  pair  of  artery 
forceps. 

This  operation  being  aseptic,  the  wound  is  to  be  carefully  sutured 
to  prevent  hernia,  which  is  very  liable  to  occur  after  incisions  in  this 
part  of  the  abdomen,  and  no  drainage  is  necessary.  The  mortality 
of  such  an  operation  by  experienced  men  is  not  over  one  or  two  per 
cent.,  which  goes  to  strengthen  the  position  taken  by  Morris,  that 
such  an  operation  is  less  dangerous  than  any  attack  of  appendicitis. 

To  avoid  the  damage  to  the  abdominal  wall,  which  is  caused  by 
this  incision,  McBurney  has  devised  the  following  : 

"A  skin-incision  about  three  inches  long  is  made,  beginning  at  a 


652  SURGERY   OF   THE   RECTUM   A^B   PELVIS. 

point  one  inch  above  the  line  drawn  from  the  anterior  iliac  spinous 
process  to  the  umbilicus,  passing  obliquely  downward,  crossing  that 
line  at  a  point  one  and  one-half  inches  internal  to  the  spinous  proc- 
ess, and  corresponding  as  accurately  as  possible  in  direction  to  that 
of  the  fibres  of  the  external  oblique  muscle  and  aponeurosis.  The 
section  of  the  external  oblique  should  really  be  a  separation  of  the 
fibres  of  this  structure  in  a  line  corresponding  to  the  skin -incision, 
great  care  being  taken  not  to  cut  any  fibres  across. 

"When  the  edges  of  the  wounds  in  the  external  oblique  are  now 
pulled  apart  with  retractors,  a  considerable  expanse  of  the  internal 
oblique  muscle  is  seen,  the  fibres  of  which  cross  somewhat  obliquely 
the  opening  formed  by  these  retractors.  With  a  blunt  instrument, 
such  as  the  handle  of  a  knife  or  closed  scissors,  the  fibres  of  the  in- 
ternal oblique  and  transversalis  muscles  can  now  be  separated.,  with- 
out cutting  more  than  an  occasional  fibre,  in  a  line  parallel  with  their 
course — that  is,  nearl}^  at  right  angles  to  the  incision  in  the  external 
oblique  aponeurosis.  Blunt  retractors  should  now  be  introduced 
into  this  interval  and  the  edges  separated.  The  fascia  transversalis 
is  thus  well  exposed  and  is  then  divided  in  the  same  line.  Last  of 
all  the  section  of  the  peritoneum  is  made. 

"Two  sets  of  retractors  may  be  in  use,  one  holding  open  the 
superficial  wound  from  side  to  side,  the  other  separating  the  edges 
of  the  deeper  wound  from  above  downward.  A  considerable  opening 
is  thus  formed,  through  which,  in  suitable  cases,  the  caput  coli  can 
be  easily  handled  and  the  appendix  removed.  The  appendix  having 
been  taken  away,  the  wound  in  the  peritoneum,  which  is  transverse,  is 
then  closed  by  suture  ;  the  similar  wound  in  the  fascia  transversalis 
is  also  sutured.  The  fibres  of  the  internal  oblique  and  transversalis 
fall  together  as  soon  as  the  retractors  are  withdrawn,  and  with  a 
couple  of  fine  catgut  stitches  the  closure  can  be  made  more  complete. 
The  wound  in  the  external  oblique  aponeurosis  is  sewed  with  catgut 
from  end  to  end.  When  the  operation  is  completed  it  will  be  seen 
that  the  gridiron-like  arrangement  of  the  muscular  and  tendinous 
fibres  to  which  the  abdominal  wall  largely  owes  its  strength  is  re- 
stored almost  as  completely  as  if  no  operation  had  been  done." 

The  incision  in  perforative  cases  should  be  made  over  the  outer 
side  of  the  tumor  when  such  exists  near  enough  to  the  anterior  ab- 


APPENDICITIS.  553 

dominal  wall  to  be  felt.  It  may  be  of  the  same  kind  as  last  de- 
scribed, but  should  be  fully  three  inches  long  in  its  deeper  parts. 
Care  must  be  taken  in  opening  the  peritoneum  lest  gut  be  injured, 
as  all  the  j)arts  are  likely  to  be  matted  together.  Care  must  also  be 
exercised  in  protecting  the  general  peritoneum  from  infection  by  the 
use  of  sponges  or  strips  of  gauze  packed  into  the  wound  at  the 
inner,  upper,  and  lower  portions. 

When  no  pus  is  encountered  in  the  breaking  up  of  adhesions  and 
separating  the  apj)endix,  the  oj)eration  is  the  same  as  in  the  last  va- 
riety, and  the  stump  may  be  treated  in  the  same  way — either  tied  and 
covered  with  peritoneum  or  inverted. 

When  pus  is  encountered  in  small  quantity  it  should  be  wiped  out 
with  sponges,  and  peroxide  of  hydrogen  injected  into  the  cavity  from 
which  it  flows  with  a  syringe.  This  in  turn  is  washed  away  by  fre- 
quent injections  of  saline  solution.  In  this  way  pus  which  is  con- 
lined  by  adhesions  may  be  removed  and  rendered  harmless  without 
breaking  down  the  partition  between  it  and  the  general  peritoneum, 
and  this  is  the  object  of  the  operator. 

AYhether  or  not  the  appendix  should  be  removed  in  such  cases 
must  depend  upon  whether  it  can  be  found  and  treated  without  dan- 
ger of  general  infection.  It  may  be  that  this  will  be  easy,  or  the  or- 
gan may  be  so  imbedded  as  not  to  be  found  at  all  without  tedious 
dissection  in  the  wall  of  the  abscess.  Often  only  the  stump  of  the  ap- 
pendix remains  between  the  colon  and  the  gangrenous  process  which 
has  divided  it.  The  appendix  should  certainly  be  removed  whenever 
possible  to  avoid  the  formation  of  a  sinus,  a  fecal  fistula,  or  a  subse- 
quent attack,  but  it  is  better  to  leave  the  diseased  organ  than  to  excite 
a  general  peritonitis  by  removing  it. 

In  all  this  class  of  abscess  cases  a  search  should  be  made  for  con- 
cretions lying  loose  in  the  abscess  cavity,  lest  the  wound  refuse  to 
heal.  Future  operation  to  close  the  sinus  remaining  from  such  a 
cause  will  be  both  difficult  and  dangerous,  and  is  to  be  guided  by  the 
general  rules  for  the  treatment  of  fecal  fistula. 

In  this,  as  in  all  other  cases,  the  treatment  of  the  wound  will  de- 
pend upon  the  question  of  infection.  Some  wounds  may  be  closed, 
when  no  pus  has  been  encountered,  all  others  should  be  drained  with 
cauze. 


•554  SUEGEEY   OF   THE   RECTUM   AND   PELVIS. 

Ifc  will  occasionally  happen  that  a  secondary  abscess  will  form  in 
these  cases  at  a  point  not  far  removed  from  the  original,  and  due  to 
failure  to  clean  out  and  remove  some  septic  focus.  This  will  be 
shown  by  a  rise  of  temperature  coming  on  after  a  longer  or  shorter 
period  of  convalescence.  No  connection  with  the  original  focus  may 
be  discoverable. 

AYhen  such  rise  of  temperature  occurs  the  wound  should  be  re- 
opened, and  search  made  for  the  new  abscess. 

Finally,  there  remains  to  be  considered  the  class  of  cases  in 
which  the  septic  peritonitis  is  diffuse  and  not  localized.  These  will 
be  quickly  recognized  when  the  peritoneum  is  incised  by  the  escape 
of  pus  and  serum,  with,  perhaps,  gas  and  faeces. 

The  wound  should  first  be  enlarged  sufficiently  to  allow  free 
access  of  the  hand  to  all  parts  of  the  peritoneum.  The  patient 
should  be  turned  on  the  side  and  all  fluid  allowed  to  flow  out  that 
will  do  so.  Next  localized  collections  of  pus  are  to  be  searched  for 
with  the  hand  and  evacuated.  The  appendix  is  to  be  removed  or  its 
stump  properly  treated.  The  whole  peritoneal  cavity  should  then 
be  flooded  again  and  again  with  hot  saline  solution  till  all  flocculi 
are  washed  awa}^  and  Douglas'  pouch  is  finally  wiped  dry  with 
sponges  in  holders.  The  drainage  should  be  as  thorough  as  possible, 
and  different  strips  of  gauze  should  reach  to  different  parts  of  the 
abdomen.  In  women,  a  posterior  colpotomy  is  often  advisable  to 
allow  of  escape  of  fluids  into  the  vagina.  The  incision  should  be  left 
open  for  at  least  three  or  four  inches,  and  the  gauze  should  be 
loosened  at  the  end  of  the  flrst  twelve  hours  to  see  that  there  is  no 
obstruction  to  the  flow  of  fluid. 

These  cases,  although  generally  fatal,  are  not  necessaril}^  so,  and 
operation  should  never  be  refused,  unless  the  patient  be  in  articulo 
mortis.  There  are  many  cases  of  recovery  even  from  this  desperate 
condition  as  a  result  of  proper  surgical  treatment. 


INDEX. 


PAGE 

Abbe's  anastomosis 333 

Abdominal  coeliotomy 391 

hysterectomy 95 

Abscess,  deep  pelvic 77 

ischio-rectal 75 

ovarian 82 

pelvic,  in  women 80-85 

pelvic,  in  women,  symptoms 82 

pelvic,  in  women,  treatment 83 

pelvic,  causing  stricture 81 

periprostatic 493 

post-partum 97 

rectal 73 

vulvar 113 

Actinomycosis,  cause  of  fecal  fistula 328 

Adeno-papilloma  of  rectum 198 

Adossement,  anastomosis   by 345 

Alexander's   operation 450 

Aloe's   speculum 32 

Amputation  of  Cervix 422 


penis . 


483 


Anastomosis,  end  to  end 342 

lateral  implantation 346 

Maunsell's 339 

of  intestine 333 

with  Murphy's  button 343 

Andrew's  rectal  sound 27 

Ano-rectal   syphiloma 248 

Anus,  artificial,  closure 328 

35 


556  INDEX. 

PAGE 

Anus,  artificial,  formation 310 

indications  for 310 

sacral 303 

sphincteric  action 325 

Szymanowski's  oj)eration 332 

tmss 394 

Anus,  fissure   of 212 

imperforate 51 

treatment 58 

Anus,  strictui-e  of 273 

Appendicitis, 545 

catarrhal , 550 

causes 543 

diagnosis 548 

fistula  following  operation 533 

incisions  for 549 

inyersion  of  stump 552 

operations 549 

symptoms 547 

Arteries,  uterine  and  ovarian 421 

Artificial  anus,  closure 330 

formation , 310 

indications  for 310 

sacral 303 

sphincteric  action 325 

Bacon's  operation  for  stiictui'e  of  rectum 269 

Bardenheur's  incision  for  cancer  of  rectum 295 

Bassini's  operation  for  inguinal  liemia 467 

femoral  hernia 474 

Bigelow's  evacuator 505 

lithotrite 505 

Bladder,  exstrophy 514 

irrigation > 512 

rupture 501 

Bougie,  rectal,  Andrew's 27 

scale  of  sizes 29 

soft 27 


INDKX.  557 

PAGE 

Button,  Murphy's 342 

Buttouliole    operation 443 

Calculus,  renal 520 

ureteral 543 

vesical 503 

Cancer  of  prostate 497 

rectum 276 

rectum,  choice  between  extirpation  and  colostomy 286 

rectum,  colostomy ', 311 

rectum,  diagnosis 284 

rectum,  extirpation  by  perineum 290 

rectum,  extirpation  by  vagina 292 

rectum,  involvement  of  lymphatics 284 

rectum,  Kraske's  operation   293 

rectum,  limits  of  excision    287 

rectum,  radical  cure 288 

rectum,  treatment 285 

Carcinoma  Uteri,  amputation 419 

Caruncle  of  urethra . .  444 

Casper's  ureter-cystoscope 537 

Castration,  male 488 

Catgut,  preparation 40 

Catheter,  uterine 84 

Catheterization  of  ureters 530 

Cautery,  Paquelin 47 

Cervix  uteri,  amputation 419 

uteri,  carcinoma 419 

uteri,  high  amputation 419 

uteri,  wedge-shaped  amputation 422 

Chancre,  anal 242 

cause  of  stricture 240 

rectal 243 

Chancroid,  rectal   237 

rectal,  phagedenic 240 

rectal,  treatment    24] 

Circumcision    482 

Clamp  and  cautery  for  hemorrhoids 148 


558  INDEX. 

.    PAGE 

Clamp,  Author's 148 

intestinal 293 

Smith's   148 

Cleveland's  ligature-carrier 88 

suture  in  perineorrhaphy 43(> 

Clover's  crutch    44 

Coeliotomy,  abdominal .   391 

after  treatment 406 

closure  of  wound 405 

complications 407 

hemorrhage  after 407 

intestinal  paralysis  after 408 

opium  after 410 

sepsis  after 410 

shock  after 407 

Coeliotomy,  vaginal 86-441 

volvulus   after 409 

vomiting  after 408 

Colon,  mesentery  of 316 

Colostomy 268 

closure  of 328 

complications  in  performing 326 

evacuation  of  bowels  after , 324 

for  cancer  of  rectum 311 

for  intestino-vesical  fistula 126 

hernia  after 326 

incision  for  lumbar 314 

inguinal 317 

invagination  of  lower  end 323 

lumbar 313 

provisional 306 

sphincteric  action  after 325 

technique  of  operation 318 

with  closure  of  distal  end  of  gut 322 

with  lateral  approximation  of  ends 324 

with  short  mesentery 326 

Colpo-perineorrhaphy 428 

Colpotomy,  anterior 440 


INDEX.  559 

PAGE. 

Colpotomy,  posterior » .  .  „  o . .  „ .  =  ..  o  ..  =  .,.  = 440 

Condyloma  of  auus 205-244 

Congenital  malformation  of  rectum 50 

Constipation 350 

causes 352 

in  children   356 

results 354 

treatment 355-358 

unusual  cases 351 

Cryptorchidism 485 

Curettage  of  uterus 83 

Curette 84 

Cyst,  dermoid,  of  ovary 403 

Cystocele 413 

Emmet's  operation 435 

Stoltz's  operation 436 

Cystoscope   537 

Cystotomy  in  female 445 

bilateral 503 

lateral 503 

median 503 

supra-pubic 508 

Czerny  suture  for  ventral  fixation 448 

Czerny-Lembert  suture 341 

Defecation,  physiology 350 

Dermoid  cyst  of  ovary 403- 

Diabetes,  causing  pruritus 369 

Dij^htheritic   proctitis 66 

Directors  for   fistula 108 

Drainage-tubes 43 

Dressings,    preparation 42 

Dupuytren's  enterotome 330 

Dysenteric    stricture 252 

ulceration 222 

Dysentery 66-222 

Edebohls's  leg  supporter 25 

method  of  preparing  catgut 453 


560  INDEX. 

PAGE 

EdeboMs's  operation  for  shortening  the  round   ligaments 450 

Ectopia   testis . , , 486 

Emmet's  button-hole  operation 443 

operation  for  cystocele 435 

Enterotome  of  Dupuytren 330 

Epispadias 481 

Estheomene 219 

Evacuator,  Bigelow's 506 

Examination  of  rectum,   high 33 

Examination  of  rectum,  comphcations 307 

Excision  of  rectum,  incision 295 

of  rectum,  technique 299 

Exstrophy  of  bladder 514 

Extirjpation  of  penis 484 

FiECES,  impaction  of , 361 

Fecal    fistula,   after  extirpation  of  the  rectum 305 

causes 328 

closure 328 

Femoral  hernia,   Bassini's   oj)eration 474 

Fissure    of   anus 212 

of  anus,  from  pin- worms 228 

of  anus,  inflamed 212 

of  anus,  in  children 228 

of  anus,  symptoms 224 

of  anus,  treatment 228 

Fistula,  fecal,  after  extirpation  of  rectum 305 

causes 328 

closure 328 

Szymanowski's   operation 332 

Fistula,  horse-shoe 109 

intestino-vaginal 126 

intestino-vesical 124 

Fistula  in  ano 98 

blind  internal  100 

complicated  forms 311 

deep 100 

directors  for 108 


INDEX.  561 

PAGE 

Pistula  in  ano,  incontinence  after  operation 117 

treatment    103 

tubercular    101 

Fistula  knife 116 

recto-urethral 124 

Fixation  of  uterus 447 

Foreign  bodies  in  rectum 370-376 

bodies  swallowed 374 

laparotomy 382 

■Gangrenous  cellulitis  around  rectum 71 

Genito-urinary  organs,  diseases  in  male 481 

urinary  tuberculosis    , 513 

Gonorrhoea  of  rectum 236 

•Growths  of  rectum,  non-malignant 193 

Gummata  in  rectum 248 

Hagedorn  needles 88 

Heger's  colpo-perineorrhaphy 428 

Hemorrhage  after  coeliotomy , 407 

from  rectum 48 

in  oophorectomy 404 

Jlemorrhoids 128 

capillary • 135 

clamp  and  cautery  operation 148 

excision 152 

external  cutaneous 133 

external  venous 129 

forceps  for  operation 148 

gangrene 139 

injection  of 144 

internal 135 

ligature  of 142 

reflex  symptoms 138 

strangvilation 139 

symptomatic 140 

treatment 142 

treatment  after  operation 150 


562 


INDEX. 


Hemorrhoids,  treatment  of  external 130 

venous , I35 

Whiteliead's  operation 152 

Hernia,  after  colostomy 326 

inguinal,  radical  cure 461 

inguinal,  radical  cure,  accidents 466 

inguinal,  radical  cure,  Bassini's  operation 466 

inguinal,  radical  cure,  Halstead's  operation 470 

inginnal,  radical  cure,  indications  for  operation 461 

inguinal,  radical  cure,  in  infants 461 

inguinal,  radical  cure,  in  inflamed 462 

inguinal,  radical  cure,  in  irreducible > 461 

inguinal,  radical  cure,  in  obstructed 462 

inguinal,  radical  cure,  mortality 462 

inguinal,  radical  cure,  results 462 

inguinal,  radical  cure,  suture  material 462 

Hernia  of  rectum 160 

of  rectiim,  diagnosis 162 

umbilical 480 

ventral,  following  appendicitis 475 

ventral,  operability 477 

ventral,  operation 477 

Herpes  of  anus 212 

Hochenegg's  incision  for  extirpation  of  the  rectum 295 

Horseshoe  fistula 109 

fistula,  operations  for 109 

Hydrocele , 488 

Hypertrophy  of  cervix 420 

of  cervix,  supra-vaginal 420 

of  prostate 495 

Hypospadias 481 

Hysterectomy,  abdominal 95 

supra  vaginal 95 

vaginal    89 

Impaction  of   fseces 361 

of  fseces,  treatment  of 363 

Imperforate  anus 51 


INDEX.  563 

PAGE 

Imperforate  anus,  treatment  of 58 

Implantation,  anastomosis   by  lateral 346 

Incontinence,  fecal,  following  operation 118 

cure  of , 120 

Inguinal  colostomy 317 

Inguinal  hernia,  radical   cure   of 461 

radical   cure,  accidents 466 

radical    cure,  Bassini's  operation 466 

radical  cure,  Halstead's  operation »^ 470 

radical   cure,  indications   461 

radical    cure,  in  infants 461 

radical    cure,  in  irreducible 461 

radical    cure,  inflamed 462 

radical   cure,  in  obstructed 462 

radical   cure,  mortality 462 

radical   cure,  results 462 

radical   cure,  suture  material 462 

Insufflator,  rectal 231 

Internal   urethrotomy 490 

Intestinal  anastomosis 333 

clamp 293 

paralysis  after  coeliotomy 408 

resection 333 

Intestino-vaginal  fistula 126 

vesical  fistula 124 

Intussusception, , 1'72 

adhesions ■    181 

anatomy 178 

chronic 184 

component  parts I'^S 

diagnosis 174-185 

Maunsell's  operation 190 

prognosis • 184 

sloughing 182 

sulcus 1'^'^ 

symptoms 183 

treatment 187 

Irrigator 44 


564  INDEX. 

PAGE 

Irrigator  rectal 231 

Ischio-rectal  abscess 75 

Israel's  line  of   incision  for  ureter 531 

Kangaroo  tendon  sutures. 463 

Kelly's  leg-holder 45 

speculum 33 

ureteral  catheters 530 

ureteral  sounds 531 

Kelsey's  speculum 31 

Kidney,  catheterization 533 

suppurative  disease 524 

wounds 525 

Knife,  flexible  for  fistula 116 

Kraske's,  excision  of  rectum 293 

excision  of  rectum,  complications .    307 

Lacerated  cervix,  bilateral 415 

denudation 416 

forceps  for 419 

operations 416 

results 412 

scissors 419 

stellate 414 

symptoms  of 411 

Lacerated  perineum 425 

complete 433 

sutures  in 417 

Laparotomy  for  foreign  bodies  in  rectum 382 

Le  Fort's  operation 438 

Lembert's  suture 340 

Levator-ani  muscle 10 

Ligature-carrier 88 

Ligatures,  preparation 39 

Litholapaxy 505 

Lithotrite,  Bigelow's 505 

Lumbar  colostomy 313 

colostomy,  incision 314 

Lupus  of  anus 219 


INDEX.  565 

PAGE 

Malformation  of  rectum 50 

Malposition  of  testicle 485 

of  testicle  femoral 487 

of  testicle  perineal    486 

of  testicle  pubic 487 

Masturbation,  rectal 235 

Maunsell's  anastomosis 338 

Mesentery  of  colon 316 

Metretis,  amputation  of  cervix 419 

Morgagni,  columns  of 7 

Mucous  patch,  anal  244 

patch,  rectal 246 

Murphy's  button 342 

Nephkectomy    521 

effect  on  other  kidney 522 

indications    521 

Nephrorrhaphy 515 

incision    517 

Nephrotomy 519 

Neuralgia  of  rectum 389 

Needle-holder 88 

Needles,  Hagedorn 88 

Ointment  applicator  for  rectum 232 

Oophorectomy 391 

adherent  intestine 399 

adherent  omentum 399 

after  effects 406 

closure  of  wound 404 

complications 399 

conservatism , 396 

diagnosis   before 391 

drainage 401 

dressings 405 

hemorrhage  in 404 

instruments , 394 

irrigation 398 


566  INDEX. 

PAGE 

Oophorectomy  knots  in  ligatures 400 

operating  table 393 

preparations 302 

toilet  of  peritoneum 401 

treatment  of  stump 401 

pus-sacs 402 

Operations,  antisepsis 36 

for  lacerated  perineum 425 

general  rules 36 

preparation  of  patient 37 

sterilization 83 

Opium,  after  coeliotomy 410 

Ovarian  abscess 82 

artery 421 

Ovariotomy  pad 44 

Ovary,  conservative  surgery  of 396 

Papilloma  of  rectum 198 

Paquelin  cautery 47 

Pawlik's  metliod  of  ureteral  catlieterization 532 

Paederasty , 234-236 

Penis,   amputation  of 483 

extirpation  of 484 

Periprostatic  abscess 493 

Pelvic  abscess  causing   stricture 81 

in  men 78 

in  women 80 

in  women,  treatment 83 

in  women,  symptoms 82 

examination  in  women 25 

Perineorrliapliy i 425 

Cleveland's  suture 430 

denudation 429 

Perineum,  old  laceration,  complete , 432 

old  laceration,  incomplete 426 

Periproctitis , . .  65 

Phagedena  of  rectum 240 

Pile,  sentinel 215 


INDEX. 


£07 


PAGE 

Pockets  of  rectum 211 

Polypus,  fibrous 199 

glandular • 195 

symptoms 200 

villous 194 

Post-partum  abscess 97 

Preparations  for  operation 46 

Proctitis 65 

treatment "^0 

Prolapse  of  rectum,  amputation 168 

cauterization 169 

inflamed 158 

palliative   treatment 164 

pelvic  fixation 1''3 

resection 1''^^ 

strangulation 164 

treatment 163 

Prolapse  of   rectum,  ventral   fixation I'^^l 

of   urethra 444 

Prolapsus  uteri 437 

amputation  of  cervix 419 

Le  Fort's  operation 488 

Prolapsus,  varieties  of 154 

Prostate,  cancer  of 497 

hypertrophy 495 

hj^jertrophy,  castration 496 

Prostatectomy 496 

Prostatitis  acute 493-494 

Pruritus  ani 364 

cauterization 367 

changes  in  skin 365 

diabetic 369 

treatment 367 

Pyelitis,  catheterization  of  ureters 534 

Pyosalpinx 82 

Rectal  hernia 160 

hernia,  treatment 191 


568  INDEX. 

PAGE 

Recto-urethral  fistula 123 

Recto- vaginal  fistula , 126 

Reeto-vesical  fistula 124 

Rectum,  absence  of 51 

after  excision 302 

anatomy 1 

arteries 13 

cancer 276 

catarrhal  ulceration . , 211 

chancroids 237 

closed  by  uterus 448 

curves 1 

dissection 2 

dissection  in  female 298 

dissection  in  male 297 

diverticulum 64 

divisions , 2 

examination 20 

foreign  bodies 370-376 

gonorrhoea . . , 236 

gunshot  wounds o 373 

horizontal  section 5 

lymphatics 18 

minute  anatomy 6 

mucous  membrane 9 

muscles 10 

nerves 17 

neuralgia 389 

packing 49 

pockets 211 

polypoid   growths 196 

reflexes 138 

sacculi 7 

surgical  relations 3 

third  sphincter 19 

treatment  of  foreign  bodies 380 

vegetations 202 

veins 14 


INDEX.  569 

PAGE 

Rectum,  venereal  diseases  of 236 

wounds 370 

wounds  by  enema 371 

wounds,    complications 373 

Reflexes  from  rectum 138 

Renal  calculus 520 

sounding  kidney  for 53& 

Resection  of  intestine 333 

Retractors,  vaginal 87 

Rizzoli's  operation 62 

Rodent  ulcer  222 

Rupture  of  bladder 501 

of  bladder,  treatment 502 

Rydyger's  osteoplastic  resection 296 

Salpingectomy 391 

Scissors  for  perineorrhaphy 428 

Seminal  testicles,  chronic   inflammation 497 

testicles,  removal  of 497 

Sentinel  pile    215 

Sepsis  after  coeliotomy    410 

Shock  after  coeliotomy    407 

Shortening  round  ligaments,  accidents 460 

^             round  ligaments,  incision 452 

round  ligaments,  suturing , 456 

round  ligaments,  "Wylie's  operation 459 

Sims's  speciilum 31 

Sodomy , .    238 

signs  of 234 

Spasm  of  sphincter  ani 386 

Spasmodic  stricture  of  rectum 251 

Speculum,  Aloe's  rectal 32 

Author's  rectal 31 

Kelly's  rectal 33 

loaded  vaginal 84 

self-retaining  vaginal 84 

Sims's  rectal • 31 

Sphincter  ani,  after  extii'pation 306 


570  INDEX. 

PAGE 

Sphincter  ani,  laceration  ...    , 411 

ani,  spasm 386 

ani,  stretching 32 

ani,  third 19 

Sponge-holder 43 

SiJonges,  preparation 43 

Sterilizers 41 

Stoltz's  operation  for  cystocele 436 

Stricture  of  rectum 250 

of  rectum,  anastomosis  around 269 

of  rectum,  caused  by  pelvic  abscess 81 

of  rectum,  chancroidal 239 

of  rectum,  diagnosis 259 

of  rectum,  dilatation 265 

of  rectum,  dysenteric 252 

of  rectum,  excision 268 

of  rectum,  from  pressure 250 

of  rectum,  incision 266 

of  rectum,  inflammatory 253 

of  rectum,  non-malignant 250 

of  rectum,  pathology 255 

of  rectum,  spasmodic 251 

of  rectum,  symptoms 251 

of  rectum,  syphilitic 68 

of  rectum,  traumatic 254 

of  rectum,  treatment 263 

of  rectum,  tubercular 254 

of  rectum,  varieties 250 

of  rectum,  venereal • 255 

of  ureter ...... 542 

Supra-pubic  cystotomy 508 

Supra- vaginal  hypertrophy  of   cervix 420 

hysterectomy 95 

Suture,  Czerny-Lembert 341 

intestinal,  adossement , 346 

intestinal,  end  to  end 342 

intestinal,  forms  of , 340 

intestinal,  Lembert's . . . » . , , . 340 


INDKX.                                            .  571 

PAGE 

Syphilis  of  Tectum 244 

of  rectum,  stricture 68-253 

Syphilitic  condyloma 207 

ulceration  of  colon 245-247 

Syphiloma,  ano-rectal 248 

Syringe  for  injecting  bladder 510 

Szymanowski's  operation 331 

Testicle,  misplaced 485 

misplaced  femoral 487 

misplaced  perineal 486 

misplaced  pubic 487 

Thiersch's  solution,  formula 513 

Traumatic  stricture  of  rectum 254 

Truss  for  artificial  anus , 304 

Tubercular  fistula 101 

stricture  of  rectum 254 

ulcers  of   rectum 217 

Tuberculosis,  genito-urinary 513 

Tumors,  congenital,  of  anus 209 

Ulcer  of  rectum,  dysenteric 222 

of  rectum,  irritable 213 

of  rectum,  rodent 220 

of  rectum,  traumatic 210 

of  rectum,  tubercular 214-217 

Ulceration   of  colon,  syphilitic 245 

of  rectum,  catarrhal 211 

of  rectum,  diagnosis 226 

of  rectum,  non-malignant 210 

of  rectum,  symptoms 225 

of  rectum,  traumatic 210 

of  rectum,  treatment 227 

of  rectum,  tubercular 217 

of  rectum,  varieties   210 

Umbilical  hernia 480 

Urachvis,  persistent 515 

Ureter  calculus 543 


572  INDEX. 

PAGE 

Ureter  eatheterism 530 

cystoscope 537 

examination 527 

relations 528 

stricture 542 

surgery 527 

wounds ._ 541 

Ureteritis 542 

Urethra,  caruncle 444 

laceration   in   male 484 

prolapse 444 

Urethrocele 442 

Urethrotomy,  drainage  after 492 

external 490 

external  with   guide 490 

external  without   guide 491 

internal 490 

Uterine  artery 421 

catheter  .  , 84 

dilator 84 

Uterus,  fixation  of 447 

retroversion  of 448 

Vagina,  operations  on 411 

Vaginal  coeliotomy 441 

fixation  of  uterus 447 

hysterectomy 89 

retractors 87 

Van  Dittel's  incision  for  seminal  vesicles 499 

Van  Hook's   operation  on  ureter 542 

Varicocele 488 

operations 489 

Vegetations  in  rectum ...    202 

Venereal  disease  of  rectum 233 

stricture  of  rectum 255 

Ventral  fixation  of  uterus 447 

fixation  of  uterus,  Czerny's  suture 447 

fixation  of  indications 449 


INDEX.  573 

PAGE 

Tentral  hernia 476 

hernia  following  appendicitis 478 

hernia  operability . . . .  , 477 

hernia  operations 477 

Vesical  calculus 503 

Volvulus  after  coeliotomy , 409 

Vomiting  after  coeliotomy 408 

Vulvar  abscess 114 

Women,  pelvic  examination 22 

Wounds  of  kidney  525 

of  rectum 370 

Wylie's  operation,  shortening  round  ligaments 460 

Zuckerkandl's  incision  for  removal  of  the  seminal  vesicles 500 


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